Table of Contents

Eligibility verification

In the initial process of claim review where we check the claims for simple errors and omissions, if left undetected can lead to significant costs. So, it is important to verify patient identity and eligibility to ensure that any missing data is immediately acquired for generating a complete claim. During the review, the reviewer must ensure that the data provided in the claim documents can be verified and backed by original source documents.

Verification of fraudulent/ duplicate claims

When a claim is submitted to the Payer for reimbursement, it is checked whether the claim is duplicate or fraudulent and if it needs checking on a few parameters. This involves checking if the insurance coverage is active, followed by ensuring that the diagnostics and procedure codes match the codes listed on the claim, filing of claims well after the deadline, and other types of fraud.

Coding, Bundling, and Diagnosis review

Evaluation of pre-certification or authorization records to identify cases where there is an absent or invalid pre-certification issue. Such cases are liable to take place when the diagnosis, procedure, or date of service cannot be correlated to the information provided in the pre-certification or authorization.

Detailed analysis of provider

Cross-verification of the claims should be conducted for evaluating the claims’ authenticity. It helps to rule out cases where unlisted procedures were implemented on patients despite not having a medical necessity. For this, it is important to verify if every necessary document is in the required order for the claim to be processed successfully. This helps to avoid delays and denials of claim settlements.

Benefit determination

Benefit determination is the process by which claims information is matched with benefit information to confirm whether the services delivered are covered under the terms of the member’s defined health benefits and if all the corresponding benefit adjudication rules are applicable.

Appeals processing

If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. You can ask your insurance company to reconsider its decision and they have to explain why they’ve denied your claim or ended your coverage

A small population of members drives the majority of healthcare costs. Although accurate identification and categorization of members is just the starting step, it is critical in creating the roadmap for dealing with possible member healthcare costs and experiences. The internal departments of payers should act more connected than before to ensure a free-flow of member information, bringing in a 360-degree view of the member’s condition.

Most health plans consider this as an internal exercise, but involving the member will do more benefit to the program. Members should be aware of key initiatives and efforts of the payer to improve health by regular monitoring. This awareness helps in sourcing key data specific to socio-economic conditions, which are rarely captured in the clinical visits. The framework will be applicable for members enrolling in various types of plans like Medicare, Medicaid, commercial, or group health insurance. However, it is critical to consider the member’s demographic information while categorizing for risk calculations, accordingly direct the member to correct the department that can help members to improve health.

• Accurate analysis of the validity of claims to detect fraud and identify duplicate claims to prevent revenue loss.
• Validation of data against adjudicating systems and computation of the valid claim amount for profitable collections.
• Machine-assisted adjudicated claims process with result-driven project plans tailored to your needs.
• Process transparency for enhanced collaboration with our clients; client-specific training for operational excellence.
• Compliance with HIPAA regulations and ever-changing guidelines for the maximum security of confidential information.