If your company is looking for fight fraud, control costs, increase productivity and free up staff to focus on core competencies, consider outsourcing your medical claims adjudication processing.
When selecting a provider, it’s important to choose one with the knowledge and experience required for this often complicated process. Adjudicators should receive comprehensive training in procedures, techniques and judicial requirements. They should also be trained on your specific adjudication platform and receive continuing instruction to guarantee they remain knowledgeable with regards to ever-changing adjudication information.
The claims adjudication process should offer:
- Adjudicating entitlement
- Identifying duplicate claims
- Analyzing validity of claim/fraud detection
- Extricating “data components” from raw claims
- Calculating valid claim amount
- Establishing medical service provider type
- Validating data against adjudicating engine
- Committing fully adjudicated claims
Your company has unique, specific requirements, so it’s important to choose a provider that will work with you to create a detailed project plan, verify your requirements and determine the factors that will spell success for your company. It’s also important to develop a comprehensive communication plan to define channels, and client-specific training should be conducted in collaboration with the provider’s project managers. Finally, operations should begin with full-supervision with 100 percent auditing until the team-intraining becomes proficient, earning your certification.