Claims processing – The concerns of vendor and customer with solutions

It’s official that the insurance industry cannot survive without claims processing. This process can be tagged as one of the most important tasks conducted in the back office to save money. The process is based on some defined rules as well as guidelines. Most insurers have availed this concept and transformed their processing to lower-costs location offshore.

This process is simple. It projects issues related to both vendor and customer. It is quite likely that the customer may come across with regulatory analysis, risks to privacy, abrasion and unexpected expense where the vendors may come across with unachievable goals for customer satisfaction.

Here is an explanation regarding the concerns of customers and vendors related to insurance claims processing:

1. Concerns-customer side:

There are several industries where regulation by the government or scrutiny is a must-have process for punctuality and accuracy of claims. Here, the elapsed time to process a claim is defined as the total of the time required to undertake important processes by both the vendor and the customer. Any sort of delays, especially systematic ones can prove to be expensive ¨C and result into lawsuits or regulatory action. Customer abrasion is a result of undue denials.

Business rules govern claims processing whereas the internal communication between the claims reexamination and early adjudication may vanish ¨C and insured parties may face burdens related to undue procedures that may affect the loyalty of customer and company reputation.

Most undue approval leads to extra money being paid out. These errors result in loss of the informal knowledge and network existing within a claims processing organization. It is very important to focus on privacy concerns. Most of the claims include non-public financial information and also contain protected health information. It is also a fact that most claims need manual processing. Exposure of protected health information regulated by HIPAA is important to vendor staff.

The process may prove to be more difficult that imagined. An outsourcing plan is equipped with customer qualified staff and their skills. When it comes to bring this process in-house or to some other vendor, it is a difficult process that consumes time and is expensive.

2. Concern-vendor side:

Vendors also face risks in claims outsourcing. The reason is that these claims are exposed to an automatic adjudication process. With the increase in auto-adjudication rates, the manual processing requirement for claims decreases. This results in reduction of the claims that is processed by the vendor. This results in vendor margin reduction.

The solution:

Claims processing success can be achieved via certain developing and enhancing processes and procedures. Another significant point to take into consideration is clarity within the captured nuances.

As a payer organization, you can achieve success in claims processing through some developing and enhancing processes as well as procedures. You should know that increasing your health insurance claims processing automation. You should also focus on reducing the costs of administration. The key elements of improving your claims throughput and turn-around time are health care outsourcing and health insurance claims processing accuracy.

Infosys has come up with a confluence of these factors via creating powerful segments in health care outsourcing like health plan administrative infrastructure management, revenue cycle management and health insurance claims processing. The company emphasizes on targeting as well as managing core processing cost crucial financial improvements for the plan performance of your organization. Transactional efficiency is the key element of health insurance claims processing services here.

The services offered by infosys and other such companies on the line comply with the regulations of HIPAA to simplify the process of administration.

The offerings include the services with claims management system’s functional aspects as mentioned below:

  1. The outsourcing solutions promises savings related to advanced process engineering savings and cost. Both these elements are crucial for functions and processes related to health care outsourcing and claims management. An integrated IT and BPO solution is also ensured by infosys for claims management. This helps vendors to develop and successfully manage their claims technology platform.
  2. Services such as tracking manual interventions, pricing, pre-adjudication, development of work-flows for planning and system routing are successfully implemented.
  3. Vendors can easily enhance the clients system capabilities to adhere to the latest policy. This in turn, results in better coordination of the client’s claims payments. The services can enhance systemic capacity to trap claim edits.
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