Claims Processing

Business Process Outsourcing | BPO | Benefits key 300x194When disability claims are backlogged in insurance queues, nobody wins. The insurance company’s resources become strained and it’s difficult for it to rebound to a regular process/review schedule. Disabled claimants might see delays in the fulfillment of their claims. For many of these applicants, their disability claim is a lifeline on which they depend.

From the document management standpoint, processing claims for disability forms isn’t necessarily unlike any other kind of insurance: forms come in; agents assess them. When it comes to claims for natural disasters, for example, an agent might be an expert in determining costs associated with damage from, say, a flood.

However, disability claims have an additional layer of complexity in that agents have to take on the daunting task of evaluating each claim and the medical documentation that is included to support it. These agents likely never went to medical school, but they must be fluent in understanding the language associated with the debilitating conditions described in these applications.

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Business Process Outsourcing | BPO | shutterstock 174800147 300x200Insurance companies deal with myriad of documents: annuity forms, life insurance forms and disability forms, just to name a few. As discussed previously, a business process outsourcing company can manage these types of documents more efficiently and cost-effectively, which frees up your existing staff to focus on core responsibilities.

More than that, though, a strategic BPO is able to assist with a sudden influx of paperwork, such as in the event of a natural disaster.

Natural disasters create a surge in claims

Following the winter storm in Buffalo, NY, in November, insurance companies were bracing for the worst with an onslaught of claims. They expected claims to rival the scope of claims associated with a similar winter storm in October 2006. That year, a statistical and rating advisory firm, Property Claim Services, estimated total dollar losses at $210 million. More than half of that, $150 million, stemmed from personal losses. In the weeks following the storm, a total of 63,000 policyholders filed claims, a surge that really hampered and strained insurance business operations.

For the November storm, one thing that was particularly worrisome was the threat of additional damage to property since the original damage. Rising temperatures and potential for flooding made a catastrophic response even grimmer.

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Business Process Outsourcing | BPO | shutterstock 22598401 300x200An insurance TV commercial being aired right now involves a customer talking at the camera and repeating some of the numerous questions that insurance agents need to ask when someone files a claim. One of the questions the actor repeats includes whether a dog was involved. There’s a lot for agents and adjusters to piece together, and the questions reflect that.

Those questions, though, are being filled out on just one form of several in the claims process; not to mention the different kinds of insurance-specific forms that are out there: applications, proposals and underwriting, administration and change forms, just to name a few.

The insurance industry lives and dies by paper forms. And each of these forms involves tasks related to their review and evaluation. Then, when it’s all said and done with and the claim is settled, it’s then mailed out on more paper to the respective recipients. Often, these reams of documents include redundancies in the form of copies for all the parties involved.

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Business Process Outsourcing | BPO | shutterstock 99967472 300x200The insurance industry is one of the most paper-intensive industries out there. Applications, proposals, underwriting, administration and change forms, reimbursement forms, claim forms, annuity forms, life insurance forms, health insurance forms, auto insurance forms, disability forms, supplemental medical, the administration and settlement of claims  that’s a lot of trees. Even when a claim is settled, it often results in more paper. Every insurance company would like to reduce its dependency on paper, but how does an organization get there? An experienced BPO provider can manage your paper problems with efficient document processing solutions.

Handling large stacks of paper documentation is labor-intensive and risk-laden. Everyone in the industry can save money and make better use of their time by reducing paper. This week, Property Casualty 360 released some steps to a paperless office. Here’s our abbreviated version of this useful list:

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Business Process Outsourcing | BPO | 1005631321 300x194Third in a series

In healthcare, automating every step of the pre-adjudication cycle – meaning anything that happens before the payment of a claim – allows claims to be processed more efficiently and more accurately. As claims processing improves, auto-adjudication rates rise and the total cost per claim falls.

Healthcare payers and benefit administrators are provided with pre-adjudication technologies that replace error-prone human processes and provides applications for PPO network management, document management, workflow and overpayment protection. These solutions improve adjudication rates, increase payment accuracy and enhance customer service. Simply put, business process outsourcing can provide better, faster and more cost-effective processing than any manual, in-house paper-based method.

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Business Process Outsourcing | BPO | 153490621Second in a series

The review, investigation and processing of claims can be time-consuming and prone to human error. By initiating an advanced healthcare claims processing system, you can alleviate many of these issues and ensure the accuracy of all claims processed.

Paper and electronic data interchange (EDI) claims can be imaged and converted to electronic format and transmitted back to integrate with the appropriate claim system. With a special focus on the front-end operations for claims processing, 100 percent electronic claims submission can be enabled to reduce administrative costs and improve auto-adjudication rates.

The most trusted BPO companies have made significant investments in enterprise software and infrastructure development, specifically addressing data security requirements. Annual external audits can ensure compliance; and multisite processing models can allow for superior business continuity and disaster recovery capabilities.

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Business Process Outsourcing | BPO | 78467481 300x197First in a series

For years, Electronic Data Interchange (EDI) claims submission has reduced payer rejections and administrative costs while increasing the speed of the payment. So why do EDI transactions still have adjudication issues? The reason is that the best data the provider has is simply not good enough.

Payers and providers have natural differences in update cycles, systems and business processes that contribute to adjudication errors. Payers contract with providers at longer periods than members – and members often update their information only annually.

More often than not, data is never given to the provider until an encounter, so demographic data becomes stale very quickly. This means providers have little opportunity to get patient data corrected. Plus, they have limited resources and capabilities to keep their own demographic data synchronized with every payer.

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Business Process Outsourcing | BPO | 162237897 300x225Healthcare claims processing can involve expensive and serious consequences if the data is not processed correctly. To address these issues, healthcare payers and benefit administrators are turning to digital pre-adjudication technologies to replace error-prone human processes and increase claim payment accuracy. This involves electronically organizing the data before the payment of a claim is made.

Using technology instead of manual processes allows the solution to be customized to adapt to specific business requirements and improve performance without additional capital investment. Advanced BPO providers can automate the claims process, including claim data cleaning to increase claims quality and reduce overall costs.

With the right technology, healthcare claims can be improved so that they match system files; thus, lowering reject rates and improving adjudication rates all while ensuring HIPAA security and consistency.

Automation Technology Can Advance the Claims Process

The latest automation technology can increase data accuracy, lower costs and bring faster cycle times to the healthcare claims process. The technology can automate and integrate all aspects of pre-adjudication claims processing, including cleaning and enhancing claim data.

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Business Process Outsourcing | BPO | security The security of medical records and healthcare claims is a sensitive issue recognized by industry leaders in healthcare. HIPAA compliance standards ensure that healthcare claims and related information remain secure and protected.

The most effective claims processing is accomplished with automation technology that offers advanced pre-adjudication services. These services take care of everything that happens before the payment of a claim. However, some claims still require exception processing – meaning human intervention to investigate and correct individual fields that don’t meet standards.

The option of hybrid onshore/offshore claims processing has become a model worth considering. Redaction is made possible using form definition technology to slice through each claim image, and physically separates the patient/insured section, which contains the personally identifiable information (PII), from the rest of the claim. Redaction technology eliminates any possibility of a person or software illicitly obtaining the image or OCR results for PII fields.

With this model, the fragment containing PII can be routed to a trusted onshore location for exception processing while the non-PII fragment containing provider and service lines can be routed to an offshore location for exception processing at a lower cost. This balance creates a cost-effective process that meets all state-mandated requirements.

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Business Process Outsourcing | BPO | bpo challengesLeaders in healthcare have long recognized the challenges when it comes to claims processing. Healthcare payers and benefit administrators have begun to focus on the front-end process to help reduce operational costs, increase adjudication and first-pass rates, and improve overall customer service.

Many BPO challenges in healthcare claims processing involve:

  • Claim data accuracy
  • Scrutiny of payments
  • Patient privacy demands
  • Regulatory mandates
  • Processing costs.

Inaccurate, incomplete or erroneous data – dirty data – often results from a lack of updating of claim filing with payer system records. This data must constantly be synced to allow for increased member and provider matching.

Furthermore, as a result of healthcare reform, federal agencies are initiating more robust audits, leveraging new technologies and focusing on improved healthcare processing integrity. These efforts reduce payment errors and prevent taxpayer dollars from being wasted in payments to the wrong people and in the wrong amounts.

Electronic claims are becoming an industry standard, and patient privacy is one of the most important elements of healthcare information technology. With HIPAA requiring facilities to protect their electronic medical records with the proper IT security controls, guaranteed compliance with stringent security and information safeguards is essential.

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