Healthcare Claims Adjudication Services

Outsource Healthcare Claims Adjudication Services

The healthcare industry as we know it has many moving parts which keep hospitals, healthcare providers, pharmacies, medical equipment manufacturers, pharma companies, etc. working together like a fine machine. Healthcare claims are just one of the many moving parts and are one of the most important data gathering aspects of any healthcare operation.

At the same time, a key challenge for healthcare payers lies in the variety of benefit plans, each of which must be correctly configured and accounted for. This, in turn, can severely hamper the efficiency of your medical claims adjudication process. This can cause unwanted claims, duplicated claims, delayed execution, and, eventually affect your overall profits.

We at Flatworld are experts in providing claims adjudication services for our global clients in the healthcare industry. The entire process of receiving medical claims, verifying them and settling the claims forms a huge chunk of insurance processing task. Leverage our expert claims services and benefit from partnering with a truly international Healthcare BPO service provider.

Our Healthcare Claims Adjudication Services

Outsourcing healthcare claims adjudication services is still not as prevalent as it should be, predominantly because most service providers believe in a one-size-fits-all claims adjudication process. We understand that every client has its own requirements and may need a different approach so as to achieve their goal. At FWS, our claims adjudication process takes collaboration to the next level by focusing on comprehensive communication and client-specific training which ensures close supervision and quality auditing for a better final result. Our services include -

  • Claims adjudicating entitlement
  • Validating of claims with in-depth fraud detection
  • Checking for duplicate Claims
  • Computing claims amount
  • Extricating "data" from raw claims
  • Setting up medical service provider type
  • Validating data against claims adjudicating engine
  • Committing adjudicated claims
  • Coding, Bundling, and Review
  • Benefit-based determination adjudication

Our Healthcare Claims Adjudication Process

Healthcare claims processing and claims adjudication can be strenuous and take a lot of time for your medical team to complete. Outsourcing healthcare claims adjudication to Flatworld what usually requires a lot of manpower is now completed with the help of state-of-the-art ML-driven technology and a team of experienced healthcare claims professionals. Our process includes the following steps -

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

Multi-layer Review: Our Key Differentiator

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 back 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 the 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 claims 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 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 -

  • Our claims adjudicators are experts in healthcare claims processing and process your claims with efficient analytical skills, and not like a mindless activity
  • Our adjudicators are specifically trained in US healthcare adjudication systems and processes and provide dedicated healthcare BPO
  • We know and understand the intricacies of International insurance regulations and work according to your specific needs, in compliance to international healthcare claims standards and regulations
  • We provide maximum efficiency, quick turnaround time, accurate recording and up-to-date maintenance of records
  • You can be totally confident about the security of your data as we follow stringent data security systems and legally binding security policies
  • All our processes are HIPAA-compliant ensuring strict adherence to laws and regulations
  • 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
  • We have serviced a variety of different US-based regional and national health plans representing more than 50 satisfied healthcare clients

Choose Flatworld Solutions for Outsourcing Healthcare Claims Adjudication

Over the past 13 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 your and your stakeholders.

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

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