Healthcare Claims Adjudication Services

With our healthcare claims adjudication services, we extensively review and identify mistakes in claims before submission to speed up the settlement of claims

Are you swamped with claims that require adjudication? Are you lacking the in-house expertise to handle healthcare and medical claims? If so, we have just the solution to end your woes. Our medical claims adjudication services are designed to end fraudulent claims, limit cost overruns, and add more time to the day to focus on other core competencies.

We have an expert team medical claim examiners who are highly proficient in the adjudication framework. With decades of experience in electronic and manual adjudication, we will adjudicate claims at record speeds. Our team will look for duplicates, errors, and other discrepancies that result in a delay or denial of claims.

Medical Claims Adjudication Services We Offer

Flatworld is a leading healthcare BPO that has professionally handled medical claims processing outsourcing tasks. In just 19 years we have emerged as leaders in the segment because our team of medical claim examiners stays updated on the latest fraud practices. Our claims adjudication services include -

Healthcare Claims Adjudication Process We Follow

Healthcare and medical claims adjudication is a strenuous process that requires comprehensive knowledge of the cost containment measures to fight fraud. This task becomes complicated if you do not have a skilled team to adjudicate claims with agility and precision. Outsourcing claims adjudication to Flatworld solves most of your concerns as we have people who are adept at manual and electronic claims adjudication. Our claims adjudication process is as follows -

Our Healthcare Claims Adjudication Solutions Software

Being one of the leading healthcare claims adjudication service providing companies, we believe in providing quality services within a quick time. This is made possible by leveraging the latest and best healthcare claims adjudication tools and technologies. Some of the key tools and technologies we leverage include -

Claim Types We Adjudicate

We are a world-class healthcare BPO service provider, and our professionals adjudicate the following claim types as part of our healthcare claims adjudication solutions -

Multi-layer Review - Our Key Differentiators

At FWS, we continuously try to innovate and optimize our processes by developing smaller process subsets that all our clients can identify with and get behind. Multi-layer claims review is but one example of such a sub-process, which ensures not only up to 100% accuracy but also breakneck speed which is beneficial in the field of healthcare. This includes -

1. Initial Claims Processing Review

   We believe the first step in the claims review process is also the most important since all claims with simple errors and omissions can be returned at this stage itself, thereby reducing processing load down the line. During this phase, we check for the following -

   • Incorrect patient names and other spelling mistakes
   • Incorrect identification numbers / plan numbers/ member IDs
   • Invalid or missing diagnosis code
   • Incorrect service dates
   • Incorrect service codes
   • Patient's gender mismatch

2. Automatic Claims Review

   During this phase, an in-depth check of the claims is made to get specific details pertaining to the payer's payment policies. This step is important since many incorrect payouts can be stopped at this stage itself. Issues identified during this phase include -

   • Submission of duplicate claims - Claims which have already been submitted for the same date/procedure/by the same person are flagged

   • Unnecessary Service Delivered - Occasionally claims are made for inappropriate and expensive services which could have been easily avoided for cheaper alternatives or quicker procedures

   • Invalid Diagnosis and Procedure Codes - Diagnostic and procedure codes are sometimes listed wrongly in the claims, and when caught, can save you further trouble

   • Invalid Pre-authorization - Occasionally, the diagnosis, surgery, or performed procedure fails to match with the information provided during pre-authorization

   • Deadline Timing Has Passed - If the medical claim is submitted after the deadline has passed as ascertained by your insurance policy, then the claim processing is stopped

   • Patient Eligibility - If the patient is ineligible to apply for the claim either due to claim mismatch, missed payments, etc., then the claim can be rejected in such a scenario

3. Final Manual Claims Review

   During this stage, our experienced team of medical and healthcare claims examiners starts checking the claims for the further mismatch. For the same, they may ask for copies of medical records and other relevant documentation to check the authenticity of the claim. This step is extremely crucial when claims are made for unlisted procedures and when the medical necessity for the same needs to be validated.

4. Payment Determination

   There are mainly three types of payment determinations we use at Flatworld Solutions, they include -

   • Paid - The insurance payer determines the claim can be reimbursed when the healthcare claim is considered paid

   • Denied - The payer determines that the claim cannot be reimbursed when the healthcare claim is considered as denied

   • Reduced - The procedure code can be down-coded when the billed service level is considered too high based on the diagnosis

5. Payment

   In the final stage, we submit the payment to the office supplied by the payer and is called the explanation of the payment. This includes information such as explanation reasons for the reduction in payment, denial, adjustment, etc. It also includes information such as allowed amount, paid amount, approved amount, covered amount, patient responsibility amount, adjudication date, etc.

   Our exhaustive 5-step verification process ensures all your data is verified so that improper claims are processed properly. We cover a variety of healthcare claim types for our US-based and global clients, including -

   • HCFA claims 1500 / CMS1500
   • UB92 (Single / Multi / Attachment / COB)
   • UB04
   • Dental Claims
   • RX claims
   • Medicaid
   • Foreign claims
   • Superbill
   • Medicare RP
   • Miscellaneous (complex / non-standard)
   • Pends / Correspondence
   • Enrollment Forms Processing (EFP)
   • Vision Claims

Why Are We The Preferred Healthcare Claims Adjudication Services Provider?

Some of the many reasons why partnering with us can help you realize maximum efficiency in the long term includes -

• Highly Compliant With ISO and Other Frameworks

  We know and understand the intricacies of International insurance regulations and work according to your specific needs, in compliance with international healthcare claims standards and regulations. Therefore, we are an ISO 9001:2015 certified claims adjudication services provider.

• 100% Data Security

  We are an ISO/IEC 27001:2022 certified organization which ensures that all your patient-related data is completely safe with us. You can be totally confident about the security of your data as we follow stringent data security systems and legally binding security policies.

• HIPAA Compliant Service Provider

  All our medical claims adjudication services are HIPAA-compliant ensuring strict adherence to laws and regulations.

• Affordable Services

  We provide our clients with highly affordable pricing options which will suit the clients budget and their business requirement.

• High-quality Services

  Our claims adjudicators are experts in healthcare claims processing and process your claims with efficient analytical skills, and not as a mindless activity.

• Proficient Healthcare Claims Adjudicators

  Our adjudicators are specifically trained in US healthcare adjudication systems and processes and provide dedicated healthcare BPO.

• Quick TAT

  We provide maximum efficiency, quick turnaround time, accurate recording, and up-to-date maintenance of records.

• Scalable Services

  We provide a scalable solution that enables you to avail additional resources to handle a surge in claims. Our services can be scaled up or down without a fuss.

• SPOC

  When you choose to outsource claims adjudication services to us, we will assign a dedicated project manager who will keep you always updated about the project status.

• Latest Technology and Infrastructure

  We use the latest technology in the form of web-based SaaS solutions and remote access solutions to support multiple client platforms from whichever location they prefer.

• Round-the-clock Support

  We have serviced a variety of different US-based regional and national health plans representing more than 50 satisfied healthcare clients.

Additional Services You Can Benefit From

Client Success Stories

Demographic and Charge Entry Using Kareo Software

A leading Houston-based client was looking for a partner who could help them process more than 17000 claims in a month. Our team provided the services within no time.

Read more

Healthcare Accounts Receivable Services

A leading client was looking for a partner who could provide them with healthcare account receivable services and improve their cash flow. Our team provided the services within a quick time.

Read more

Outsource Healthcare Claims Adjudication Services to Us

Over the past 19 years, we have been helping global healthcare organizations manage their unique challenges and complex issues such as unplanned volume, omnichannel client communications, claims disbursal and processing, etc. as part of our suite of healthcare BPO services. With our services, you get -

• Faster claims settlement
• Enhanced claims accuracy
• Cost-effective expertise

Contact us now and we will be glad to assist you.