Claims Processing

Business Process Outsourcing | BPO | shutterstock 223695640 300x200In 2009, the Health Information Technology for Economic and Clinical Health Act – or the HITECH Act for short – was passed alongside the American Recovery and Reinvestment Act. As a result of the passing of this new law, the need for EHR software has gone through the roof. Software Advice, a Gartner company, published a study earlier this year that showed that the number of buyers replacing their existing EHR service has increased by 59% since 2014. This remarkable statistic suggests that many EHR products are failing to meet their user’s requirements.

As the shift towards a virtual platform becomes the new-normal, we’re seeing a burgeoning industry of BPOs that claim to meet all of their user’s needs. The good news for buyers looking to adopt one of these services is that the market for them is growing and the options are numerous. The bad news, however, is that many of these operations aren’t providing the functionality its users are looking for. With various options available to choose from, it’s important for buyers to recognize whether or not a prospective service can meet these four fundamental requirements:

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Business Process Outsourcing | BPO | Veterans Administration page 300x205The Veterans Benefits Administration is in the second year of a two-year plan to overhaul its claims processing system in order to eliminate the disability claims backlog that came to a head in 2010. At that time, the administration experienced an influx in disability claim forms that strained its processing system as the population of veterans swelled. This turned into an increase in processing timeframes and, subsequently, a backlog of disability compensation claims erupted.

The administration’s goals are straightforward. By the end of FY 2015, it seeks to eliminate the backlog as well as have new claims processed within 125 days of being received and with 98-percent accuracy. The administration will achieve this by abiding by some basic best practices for transaction process solutions that “integrates people, process, and technology initiatives that incorporate VA’s strategic plan, goals, and objectives.”

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Business Process Outsourcing | BPO | hail damaged roof 300x200Attorneys and insurers are facing off in south Texas over hail litigation stemming from two particularly nasty twin storms that ravaged the area in 2012. The storm left behind $330 million in damages and a legal aftermath that includes 6,700 lawsuits that pits policyholders against their insurance companies. Specifically, the swell of lawsuits is directly tied to lawyers who, with the allure of potential damage awards and fees, reportedly flooded the area to convince homeowners to sue.

Would it have been possible for insurance companies to stave off this costly litigation before it even had a chance to gain traction? Homeowners who felt their claims weren’t being handled efficiently might have been particularly susceptible to being talked into filing lawsuits for damages. If their claims received prompt attention, would these policyholders have been less litigious? While the merits of these cases will be worked out in the court systems, insurance companies should consider ways to promptly react to any set of circumstances that might result in a surge of claims.

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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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