Claims Processing Outsourcing

Background

A leading TPA has in-house claims processing function. On a management directive, the IT team embarked on cost cutting drive, without compromising on the quality, accuracy or timelines of claims processing.

Client fully realized that their reputation, in the eyes of its customers, rides on the manner in which claims are processed. Any delay or rejections occurring due to operational errors was untenable and unacceptable.

Business Challenges

Clients was reluctant to start with, due to multiple reasons -

  • Accuracy – Require high level of accuracy in claims processing
  • Change Management – New workflows had to be defined to balance the accuracy and throughput, which needed to work efficiently across two teams
  • Proficiency – The new partner needed to be proficient in the claims management and bill review systems, currently being used by client.
  • HIPAA Compliance – The new partner needed to be HIPAA compliant
  • Subject Matter Expertise – Team assigned would need to be highly proficient in claims processing and adjudication norms
  • Operational Challenges – Included managing varying volume of claims, identify duplicate claims, fraud prevention, process standard claims as well as non-formatted claims

Methodology

Involved the following steps

Preparatory Phase

  • Creation of detailed process document combining client inputs and own subject matter knowledge.
  • Process document sign off.
  • Project manager assigned with a team of claims processing professionals, including those experienced in adjudication.
  • System set-up, testing and go-live.

Operational Phase

  • Recording daily errors, categorizing them based on type and taking necessary measures for a permanent solution.
  • Dashboard with all KPI’s shared with management on a daily basis
  • Regular update of process guideline document based on client inputs. All updates implemented after client sign off.