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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.

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 -

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 -

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Incorrect patient names and other spelling mistakes

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Incorrect identification numbers / plan numbers/ member IDs

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Invalid or missing diagnosis code

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Incorrect service dates

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Incorrect service codes

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Patient's gender mismatch

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 -

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Submission of duplicate claims

Claims which have already been submitted for the same date/procedure/by the same person are flagged

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Unnecessary Service Delivered

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

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Invalid Diagnosis and Procedure Codes

Diagnostic and procedure codes are sometimes listed wrongly in the claims, and when caught, can save you further trouble

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Invalid Pre-authorization

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

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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

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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

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.

Payment Determination

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

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Paid

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

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Denied

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

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Reduced

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

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 -

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HCFA claims 1500 / CMS1500

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UB04

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UB92 (Single / Multi / Attachment / COB)

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Dental Claims

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RX claims

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Medicaid

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Foreign claims

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Superbill

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Medicare RP

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Miscellaneous (complex / non-standard)

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Pends / Correspondence

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Enrollment Forms Processing (EFP)

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Vision Claims

Medical Claims Adjudication Services We Offer

Flatworld is a leading healthcare BPO that has professionally handled medical claims processing outsourcing tasks. In just 20 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 -

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
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Claims Adjudicating Entitlement
12
Computing Claims Amount
13
Coding, Bundling, And Review
14
Benefit-Based Determination Adjudication

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 -

1

Receive Claims Data from You

2

Check for Eligibility

3

Check to Avoid Duplicate Claims

4

Benefit Determination Applicationn

5

Analysis of Hospital Details

6

Coding, Bundling & Diagnosis Review

7

Rules-Based Edits

8

Claims Settlement

9

Claims Presentment

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 -

Additional Services You Can Benefit From

We provide HIPAA-compliant medical transcription solutions and services to healthcare providers worldwide.

If you are looking for accurate and reliable medical billing support for your company, we have got you covered. We provide 100% reliable coding services.

Our RCM services are provided by seasoned medical experts with a firm grasp of the revenue cycle management function.

Our medical coding services are provided by seasoned healthcare professionals with a firm grasp of the concepts in their field.

If you are looking for support for your pharmacy business, you are in the right place. We provide comprehensive services for all requirements.

We can remotely manage your EMR and EHR records so that they are spotlessly clean and can be relied upon to make informed decisions.

If you are looking to partner with a pioneering provider of telehealth services, you are in the right place. We use digital technologies to make healthcare accessible to all.

We have been designing and creating medical animations for over 20 years. Our seasoned animators have created animations of devices and complex concepts.

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 -

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Pends / Correspondence

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HCFA 1500 / CMS 1500

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Vision Forms

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UB92/UB04

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Miscellaneous (Complex / Non-standard)

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Enrollment Forms Processing (EFP)

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 -

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

Client Success Stories

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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
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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
Success Stories

Outsource Healthcare Claims Adjudication Services to Us

Over the past 20 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 -

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Faster claims settlement

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Enhanced claims accuracy

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Cost-effective expertise

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

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Avail best-in-class services at affordable rates

Starts @ $1280-1440 per FTE/month More details

Our Customers

Movement Mortgage
Alcon
ARI
Maximus
Redwood E-Learning Systems

AHIMA Healthcare Convention 2016

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USA

Flatworld Solutions

116 Village Blvd, Suite 200, Princeton, NJ 08540


PHILIPPINES

Aeon Towers, J.P. Laurel Avenue, Bajada, Davao 8000

KSS Building, Buhangin Road Cor Olive Street, Davao City 8000

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Important Note: For all CNC Services: You are required to provide accurate details of the shop floor, tool setup, machine availability and control systems. We base our calculations and drawings based on this input. We deal exclusively with(names of tools).

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