Outsource Medical Claims Adjudication Services

Higher Accuracy. Higher Savings

Advanced Offshore Medical Claim Adjudication Services for Enhanced Claims Settlement

MedBillingExperts provides high-quality claims adjudication outsourcing services to insurance providers as well as third party administrators. Our team of highly experienced claim adjudicators is trained on multiple adjudication platforms and have comprehensive knowledge of US healthcare reimbursement models. We leverage this expertise and back it with a well-defined process and latest technology to ensure issues like unwanted claims, delayed claim execution, and duplicate claims do not impact the revenues of our clients.

Offshore Medical Claims Adjudication Services: What We Do

When clients outsource medical claim adjudication services to us, they can back on us to provide

  • Adjudicating entitlement
  • Analyzing validity of claims/fraud detection
  • Spotting duplicate claims
  • Computing valid claims amount
  • Extricating “data components” from raw claims
  • Establishing medical service provider type
  • Validating data against adjudicating engine
  • Committing fully adjudicated claims

Unlike other healthcare claim adjudication companies, we don’t believe in providing one-size-fits-all claim adjudication outsourcing services to every client. We understand that each client has different requirements and hence have put together a team of dedicated project managers who work in liaison with you to understand requirements, determine crucial factors for success and create a customized project plan that drives results. We also take this collaboration to the next level by having a comprehensive communication plan, providing client-specific training and ensuring that all our operations begin with full-supervision and cent percent auditing until they become proficient and earn the trust of the client.

End-to-end Process Provided by an Expert Healthcare Claim Adjudication Company

MedBillingExperts provides comprehensive outsourced claim adjudication process that works the way you want it to work.

medical claims adjudication process

Multi-Layer Review – A Key Differentiator that Sets Us Apart from Other Medical Claim Adjudication Companies

The hallmark of our medical claim adjudication outsourcing services is a strict multi-layered review process that matches adjudication speed with accuracy. This includes

The Initial Processing Review

This is first step of our claims review process, wherein claims will be checked for simple claim errors or omissions, such as:

  • Incorrect patient name or spelling mistake
  • Incorrect subscriber identification number or plan number
  • Missing or invalid diagnosis code
  • Incorrect date of service
  • Incorrect place of service code
  • Patient's gender does not match the type of service

The Automatic Review

In this step, claims are checked for more specific details pertaining to the insurance payer’s payment policies. Issues identified during the step include:

  • The patient is not eligible on the date of service: This means that the insurance coverage has termed or is simply not active.
  • The diagnosis or procedure code is invalid: This means that the diagnostic codes and procedure codes listed on the claim do not match.
  • Timely filing deadline has passed: This means that the claim is submitted after the filing deadline as ascertained by the insurance payers. Typically, this deadline is around 90 to 120 days from the day of delivering the service.
  • The claim submitted is a duplicate claim: This means that a claim has already been submitted for the same date or procedure.
  • Pre-certification or authorization is not valid: This means that the diagnosis, procedure, or date of service does not match with the information provided for the pre-certification or authorization.
  • Pre-certification or authorization is not present: This means that the pre-certification or authorization that was required for delivering the service was not obtained, or the pre-certification or authorization number was not added to the claim prior to submission.
  • The service delivered is not medically necessary: This means that the claim does not indicate that the patient care was delivered at the most appropriate and affordable levels.

The Manual Review

In this step, claims are checked by experienced medical claim examiners, who may seek medical records or other documentation to evaluate the authenticity of the claim. Though this step can be done with any type of procedure, it is generally conducted with unlisted procedures to ascertain medical necessity.

Once all the three reviews are done, the payment determination step kicks-in, wherein each claim could have three outcomes, i.e., a claim could either be paid, denied or reduced. And finally, the payment step is initiated wherein the insurance company makes the full payment or dispenses a reduced amount to the healthcare delivery center along with an explanation for full or reduced payment, or in case the claim is rejected, the insurance company provides the reasons for rejection.

Diverse Range of Claims Adjudication Types Handled by an Expert Medical Claims Adjudication Company

Being an expert outsourced claim adjudication company, we are well-versed with handling every type of medical claim adjudication including:

  • Pends / Correspondence
  • UB92/UB04
  • Dental Claims
  • Enrolment Forms Processing (EFP)
  • Vision Forms
  • HCFA1500 / CMS1500
  • Medicare
  • Super bill
  • Medicaid
  • Miscellaneous (complex / non-standard)

Other Related Services Provided by MedBillingExperts

In addition to the claim adjudication services provided by standard medical claim adjudication companies, we can also provide -

Claims Processing

MedBillingExperts has a dedicated team of experts, with adequate experience and knowledge of insurance analytics, to handle the entire gamut of medical claims processing. We leverage advanced analytics models and deploy industry best practices to ensure on-time and hassle-free claim settlement. Our industry-leading processes are supported by proprietary tools to standardize processes for overall efficiency. Further, we invest significantly in insurance training which helps us keep our team motivated and abreast of the evolving regulations in the insurance sector. All this has helped us acquire unparalleled reputation in providing quality claims processing services.

Forms Processing

Our forms processing services are designed to automating the process of data collection, thereby helping your organization to eliminate human errors while reducing costs. To put it in simple words, our forms processing service extracts data from multiple entries and converts it into convenient electronic formats, which can then be safely stored and accessed from any locations.

PPO Re-pricing

Our qualified and experienced offshore healthcare claim adjudication experts are well versed with the intricate details of insurance claims re-pricing. This enables us to offer a complete range of medical claims processing for insurance claims re-pricing including:

  • Manual claims re-pricing
  • Directing re-pricing claims to the PPO
  • Claims scrutiny and validation
  • Maintaining provider tables

Insurance Fraud Detection

Using advanced analytics and predictive modeling techniques, we can predict and identify frauds, and thereby cut losses.

EDI Integration

We have put together a team of highly competent personnel, which includes experienced EDI specialists, software professionals and medical billing / coding professionals who can seamlessly navigate through the intricacies of EDI implementation. Leveraging this expertise, we can provide top-of-the-line EDI integration services with following salient features

  • Compliance with HIPAA, HL7 and CMS formats
  • Integration of EDI software across multiple applications
  • EDI integration with your organization's existing infrastructure
  • Fax to EDI and EDI to fax document processing
  • Capability to work on real-time or batch bi-directional EDI integration
  • Data integration using EDIFACT

Here’s Why You Should Outsource Medical Claim Adjudication Services to MedBillingExperts?

When you outsource medical claims adjudication services to us, your business stands to gain in the following ways:

  • High quality services
  • Quick turnaround time
  • 40% cost savings
  • Reduction in Administrative Overheads
  • Complete data security

When you outsource claim adjudication services to MedBillingExperts, you’ll partner with a medical claims adjudication company that is focused on making speed, accuracy and efficiency as the corner stone of your offerings.

Contact us today and discover the advantage of outsourcing medical claim adjudication services to MedBillingExperts.



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