The Missing Link in Claims Adjudication: Build a Strong Data Foundation

As a healthcare payer, you’re under constant pressure to process claims quickly and accurately while controlling costs, satisfying providers, and meeting regulatory demands. Many of you are held back by a critical gap—inaccurate and inconsistent data.

Adding new tools like claims editing software, policy oversight / audit, and even provider portals, while assistive around the process of nonabrasive adjudication, often fail to address the deeper issue of the data quality being utilized for the desired frictionless operation.

A Vision of a Better Way

Imagine a time when auto adjudication rates could consistently be over 90% or when “claims rework” would not equate to growing administrative costs and abrasion for your members and your providers.

What if you had provider files that were accurate well above a 95+% rate of integrity or member files that were of similar rates of accuracy?What if your confidence level of these core data files was based upon the knowledge that these core data elements were dynamically being updated across the enterprise and applicable to other critical operational functions and related artifacts of a higher and more accurate adjudication effort?

If the concept of accurate claims processing with more throughput is a constant problem on your mind, then maybe it is time to address the real problem that drives these challenges.

If these notions are appealing, and these challenges create operational gaps in your enterprise, then it is time to consider adding a robust operational data layer to unify your information and streamline claims adjudication. This is where the Coperor Health Data Management Platform (HDMP) comes in, offering a powerful solution to tackle the root cause of your challenges.

The High Cost of Data Chaos

Your struggles with claims adjudication often boil down to one core problem: messy data. It’s scattered across siloed systems, inconsistent between departments, and frequently inaccurate in that it is static in nature. In short, all of these disparate data sources create a “Shadow IT” organization that is inefficient and extremely costly and creates differing records of the same core data source.

Consider provider data: Network management, credentialing, and operations often rely on separate platforms that don’t sync. This leads to re-keyed information, mismatched definitions, and no single source of truth for your claims adjudication engine. The results hit hard: lower auto-adjudication rates as claims get flagged for manual review, higher denial rates due to errors in provider or eligibility data, operational bottlenecks from manual fixes, increased regulatory risks like non-compliance with laws such as the Prompt Pay Guidelines and aspects of the No Surprises Act, and weaker fraud detection due to the inability to see a holistic view of your data.

Patching these issues with another application doesn’t solve the underlying data problem—it often adds more silos and unnecessary system abrasion. You’ve likely experienced this when a new tool fails to align data across systems, leaving you with the same delays and errors. What you need is a shift in approach, focusing on the data itself before it even reaches your processing tools.

The Strength of an Operational Data Layer

An operational data layer, like the one Coperor HDMP provides, acts as a central hub for all your enterprise data. Unlike analytics platforms that only pull data for insights, Coperor creates a dynamic bi-directional system. It integrates information from provider systems, patient records, claims feeds, and payer networks, then cleanses and masters it for enterprise conformity. This unified, consistent data is made available to any application—such as your claims adjudication engine or customer service tools—in the format it needs, ensuring real-time synchronization across your ecosystem.

Coperor’s platform is built on a comprehensive healthcare data model, developed over 15 years, with thousands of elements across domains like provider, patient, and claims data. Its native master data management (MDM) capabilities match, merge, and de-duplicate records to establish a single source of truth. This isn’t just about storing data—it’s about making it actionable in a real-time manner for every part of your claims process.

Creating Context with Longitudinal Profiles

Coperor excels at building longitudinal profiles for members and providers, offering dynamic longitudinal views that update with each interaction. For members, this consolidates demographics, eligibility history, prior authorizations, and past claims, allowing instant verification during adjudication. For providers, it tracks specialties, geo-logistics, network status, and credentialing over time, ensuring accurate contract terms and payment decisions based on historical context. For payers, this reduces inefficient workflows, substantially improves adjudication rates, and optimizes FTE efforts. One can imagine verifying a provider’s network status at the exact time of service or confirming a patient’s authorization in seconds—these capabilities cut down manual reviews and prevent errors that lead to cost and disruption challenges for member, providers, and payers.

Clear Benefits for Claims Adjudication

With Coperor HDMP as your operational data layer, you’ll see direct improvements in claims processing. Auto-adjudication rates increase as clean, complete data reduces manual interventions. Claim denials drop when data accuracy is ensured before adjudication. Payment accuracy improves with precise application of fee schedules and benefit plans. Operational efficiency rises as staff spend less time on manual tasks. Beyond these benefits, Coperor enhances fraud detection with a unified view of data patterns and supports value-based care by linking claims with clinical insights.

Faster, accurate payments and fewer denials also strengthen provider relationships, building trust across your network. Equally important, higher auto adjudication rates because of consistent data provide less latency of key data elements used in critical analytical and operational functions that improve accuracy in actuarial/finance processes, population analytics and provider/member engagement efforts.

Aligning Data with Partners

Collaboration with providers and other partners often suffers from misaligned data. Coperor HDMP acts as a neutral space where you and your partners can view the same claims data within the context of your respective systems. You see it alongside member and enrollment details, while a provider views it with their patient records. This shared perspective, despite differing data structures, speeds up discrepancy resolution and fosters stronger partnerships, ultimately reducing errors and enhancing care coordination.

Shifting to a Data-First Mindset

Relying on application fixes for data problems isn’t sustainable. You need a data-first approach, prioritizing a unified foundation over temporary solutions. Coperor HDMP enables this by acting as the central system for your data, unifying diverse streams, maintaining quality, and syncing it across applications. Investing in this layer moves you from being overwhelmed by data to being empowered by it, streamlining claims adjudication, cutting costs, and paving the way for better health outcomes.

Take Control of Your Data Today

Don’t let fragmented data continue to slow down your claims process or strain your resources. With Coperor HDMP, you can build a solid foundation that addresses these challenges head-on, ensuring efficiency and accuracy across your operations. To learn more, check out our web site here or contact me at andrew.cone@gaine.com to learn how this platform can fit into your strategy and help you achieve lasting improvements in claims adjudication and beyond.