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Process of Medical Claims Processing at Outsource2india

Turning over accounts receivable into cash requires a systematic, planned and focused approach. Each effort must be aimed at eliminating or resolving the problem instead of merely gathering information.
Documentation of the findings is critical as it helps as a reference tool for the future.

Here's how Outsource2india's Medical Claims Process works

Evolving benchmarks by payers
1
Identifying claims outside the benchmark
2
Prioritizing claims to work on
3
Identifying problems
4
Preparing the action plan
5
Solution implementation for due claims
6

Evolving benchmarks by payers:

The first step in understanding the different payers would be to establish benchmarks for their processing. This is usually obtained from historical information like the earlier paid EOB’s (Explanation of Benefits), Denials mails, Manuals and News letters.

The benchmark should address:

  • Time frame to process the claim by the carrier.
  • Requirements such as provider number, tax ID number, pay to address etc.
  • Check lists for the requirement of
    the carrier for all blocks in the HCFA-1500 claim form.
  • Attachments, referrals and additional documentation.
  • Different plans deployed by the payer and card copies of the plans.

However, delays in processing and payments should never be built into the benchmark, as the delay may directly be the result of improper claims submission. Establishing benchmarks based on the days required by carrier to process the claims would reduce our efforts to follow up on the claim and work on accounts, which need more attention.

Identification of Claims outside Benchmark:

Once the benchmarks are established, it is essential to identify medical claims falling outside the benchmark on a weekly basis to quantify the volume and value of such claims. This could establish and identify a global pattern, which may affect the majority of claims.

Prioritize medical claims to work on:

Once the medical claims outside the benchmark have been identified, the next step would be to identify the claims to work on. This is done with the help of reports of claims by payer type and can then be prioritized and resolved.
While prioritizing the medical claims, the fillings limits by the carrier will have to be considered which is very important.

Identification of Problems:

This is the most important step. The problems and resolutions to the various scenarios need to be understood and documented on paper. Because of the complex regulations governing the medical insurance business, Insurance companies have devised various complex rules before paying a claim. The problem could be an internal data entry error, incorrect
information on the claim or an external processing delay error. When the problems are researched for solutions it is important to document the sources of information. It is also essential for resolved problems to be applied to other claims pending to the carrier to ensure that the same problem does not recur.

Prepare an Action Plan:

As soon as we identify the problem, the next step is to confirm the findings. This is done by giving it to the calling team who will confirm the understanding of the problem and gather additional information on the reasons that have caused the medical claims to get rejected.
Preparing an action plan will involve deciding the ways to get the claims paid faster. An action plan will decide the steps to be taken, including sending physicians enrollment forms, change of address letters, additional documentation, and corrected claims.

Implement the Solution to all Outstanding Claims:

Once the action plan has been drafted and confirmed the next step would be to implement the solution to all the outstanding claims that fit the criteria for such action.
This is vital since problems falling into the same category would be fixed at one go.

Outsource Medical Claims Processing to O2I

Do you require high quality, customized medical claims processing services? Why not consider outsourcing to O2I? Read more specific information about infrastructure, competency, price ranges, and benefits.

If you would like to find out more about outsourcing medical claims processing work to O2I, please fill in the inquiry form and our Client Engagement Team will contact you within 24 hours.

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