Outsource Healthcare Claims Adjudication Services

Healthcare Claims Adjudication Services

At just $4/read our healthcare adjudication services are not just cost-efficient but also a productivity booster for your business. Say goodbye to claim processing issues by choosing us

Are you swamped with claims that require adjudication? Are you lacking in-house efficiency to handle healthcare claims adjudication without costing productivity? We, at Flatworld Solutions, hear your concerns and have just the solution to end your woes. Our healthcare claims adjudication services is designed to end fraudulent claims, limit cost overruns, and add more time to the day to focus on other core competencies.

Flatworld has the best team of medical claim examiners who know rulebook of 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 delay or denial of claims.

Healthcare Claims Adjudication Services We Offer

Flatworld is a leading healthcare BPO that has professionally handled medical claims processing outsourcing tasks. In just 15 years we have emerged as leaders in the segment because our team of medical claim examiners stays updated on the latest fraud practices used to exploit benefit. Our healthcare claims adjudication services include -

01
Determination of Claims Value
02
Explanation of Benefits
03
Investigation of Claims for Duplicates
04
Adjudication of Insurance Benefits
05
Data Extraction from Raw Claims
06
Checking Data Accuracy with Claims Adjudicating Engine
07
Review of Diagnostic Code and Patient Data
08
Evaluation of Healthcare Service Provider Details
09
In-depth Claims Validation for fraud detection
10
Execution of Adjudicated Claims
11
Claims Adjudicating Entitlement
12
Computing Claims Amount
13
Coding, Bundling, And Review
14
Benefit-Based Determination Adjudication

Claim Types We Adjudicate

Flatworld Solutions is a world-class Healthcare BPO Service Provider where our professionals adjudicate the following claim types -

 Pends / Correspondence
 HCFA 1500 / CMS 1500
 Vision Forms
 UB92/UB04
 Miscellaneous (Complex / Non-standard)
 Dental Claims
 Enrollment Forms Processing (EFP)

Other Services You Can Benefit From

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

Healthcare Claims Adjudication Process We Follow

Healthcare 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 healthcare claims adjudication to Flatworld solves most of your concerns as we have people who are adept at manual and electronic claims adjudication. Our healthcare claims adjudication process is as follows -

Receive Claims Data
1
Receive Claims Data from You
Check for Eligibility
2
Check for Eligibility
Avoid Duplicate Claims
3
Check to Avoid Duplicate Claims
Benefit Determination Application
4
Benefit Determination Application
Analysis of Hospital Details
5
Analysis of Hospital Details
Diagnosis Review
6
Coding, Bundling & Diagnosis Review
Rules-Based Edits
7
Rules-Based Edits
Claims Settlement
8
Claims Settlement
Claims Presentment
9
Claims Presentment

Software We Leverage for Healthcare Claims Adjudication Services

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 -

NextGen healthcare Kareo Billing & EHR eClinicalWorks AdvancedMD brightree medisoft Athenahealth MediTouch athenahealth Billing & EHR AdvancedMd Billing Epic Billing AdvantX Billing CareCloud Billing Centricity Lytec Billing Misys Modernizing Medicine Billing & EHR Nex-tech Billing & EHR Proclaim Pulse SequelMed TotalMD Billing

Why Outsource Healthcare Claims Adjudication Services to FWS?

When you choose to partner with Flatworld for healthcare claims adjudication, we offer our industry-best competency and capability to provide a variety of healthcare services under one umbrella. Our operational efficiency and service delivery ensure your claims processing never takes a backseat and remains an important area of focus. 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 ISO 9001;2015 certified healthcare claims adjudication services provider.

  • 100% Data Security

    We are an ISO/IEC 27001:2013 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 processes 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.

  • High-qualified 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

    The Healthcare Claims Adjudication Services is 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 healthcare claims adjudication services to us, we will assign a dedicated project manager who will keep you updated about the project status at all times.

  • 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.

Client Success Stories

Demographic and Charge Entry Using Kareo Software

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
FWS Provided Healthcare Accounts Receivable Services

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

Choose Flatworld Solutions for Outsourcing Healthcare Claims Adjudication

Testimonials

Vinoth and the team at Flatworld really make my life so much easier! They never skip a beat and I recommend everyone give their services a try. They have become such an integral part of my team. I am glad I found them.

Owner,
Business Management Consultant, TX, USA
More Testimonials »

Over the past 15 years, FWS has 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 its suite of healthcare services. We seek to be the perfect corporate partner in all aspects of our operations and activities while balancing the interests of you and your stakeholders.

Contact us right away to know how our structured and focused service support can help your business.

Pricing

Pricing

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Case Studies

Case Studies

Read Case Studies to find out how we helped our clients with Healthcare BPO.

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