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Automation Technology Can Extract, Enhance & Integrate the Claims Process
The latest breakthrough processing technology can increase data accuracy, lower costs and bring faster cycle times. The technology can automate and integrate all aspects of preadjudication claims processing, including cleaning and enhancing claim data. 1. Extraction Data receipt and extraction Image pre-processing Forms classification 2. Enhancement Advanced claim validation (ACV) using claim heuristic databases Provider and member matching methodologies Exception data validation 3. Integration Customized claim system integration Secure HIPAA-compliant EDI transmissions File transfer acknowledgements
Sophisticated searching methodology and business rules can enhance provider and member file matching. Automated providermember file matching works with files to align claim data with provider and member data for improved accuracy. Business rules and industry edits can further cleanse claim data to deliver quality results closely aligned with the adjudication system. The latest advanced provider-member verification systems are backed by up to a 99 percent matching guarantee when matching claim data to member and provider files. Additionally, customized processing rules can emulate decisions made by examiners to automatically integrate and align the data. Advanced business rules such as industry edits, data crosswalks and pattern recognition technologies can combine to ensure data quality, lower costs and improve auto-adjudication rates.
We have experienced a 36% decrease in turnaround time for receipt to payment and a 33% decrease in total processing cost per claim. - Business Solutions Director, State Medicaid HMO
We reduced our volume of fall-out claims by 89%. This reduction in manual workflow allows us to dedicate staff time to cross training and other key initiatives. - Senior Director of Operations, Large Integrated Health and Cost Containment
This intelligence enables the BPO vendor to know providers to create customized instructions for each claim ,and to quickly highlight issues for correction by an exception processing team. Advanced systems use many industry data sources in addition to the context of historical claims to establish clues about the accuracy of the claim. The clues are then assessed together to come up with decisions that drive the creation of exception processing instructions custom built for exception processing each individual claim.
Partnering with a BPO provider that maintains close professional relationships with major PPO networks and clearinghouses allows for direct integration with the clearinghouses to intake EDI claims. Automation technology reconciles the difference between provider and payer data, including provider and member information. Once received, the data submitted on EDI claims is cleansed and enhanced through matching and data augmentation to synchronize the data on the claim with the data the payer expects to see. This significantly improves auto-adjudication rates. With the vast majority of data problems in healthcare introduced by synchronization issues, the percentage of improved EDI claims received can increase by as much as 90 percent when implemented correctly. In addition to data reconciliation, processing both EDI and paper claims maximizes the ability to find the greatest number of duplicate claims that providers sometimes file by printing an EDI claim to paper in an attempt to accelerate payment.
Leaders in claims processing have long recognized industry sensitivity with processing healthcare claims and related information. HIPAA compliance secures the privacy of protected health information (PHI). Most effective pre-adjudication services are accomplished with advanced technology, but some claims still require exception processing meaning human intervention to investigate and correct individual fields that dont meet standards. The option of hybrid onshore/offshore claims processing, or redaction, has become a model worth considering. Redaction is made possible using form definition technology to slice through each claim image, and physically separates the patient/insured section, which contains the personally identifiable information (PII), from the rest of the claim. Redaction technology eliminates any possibility of a person or software illicitly obtaining the image or OCR results for PII fields. In this model, the fragment containing PII can be routed to a trusted onshore location for exception processing while the nonPII fragment containing provider and service lines can be routed to an offshore location for exception processing at a lower cost. This balance creates a cost-effective process that meets all statemandated requirements. Reasons to take advantage of redaction technology include: The added assurance of knowing that PHI is eliminated for claims during all human-based exception processing activities. The promise that critical PII information does not leave the U.S. and is processed at HIPAA-compliant onshore processing locations. The price advantage and quality guarantee that comes from processing non-PII sections of the claim at a less costly offshore labor location.
Automation solutions provide health plans with the best options for paper conversion, EDI claim cleaning and disaster recovery. Many find that high-quality technology simply delivers the best value at the lowest cost for accurate claims processing. Healthcare payers and benefit administrators are provided with pre-adjudication technologies that replace error-prone human processes and provides applications for PPO network management, document management, workflow and overpayment protection. These solutions improve adjudication rates, increase payment accuracy and enhance customer service. When a health plan or benefit administrator uses a BPO provider to manage its core pre-adjudication process, related services like mailroom and clearinghouse integration can become significantly less expensive to conduct since the core claim data is cleaned and indexed. The technology creates faster cycle times and meets specialized demands of leading healthcare organizations, achieving a balance between solving industry challenges and compliance restrictions while improving the bottom line and the customer experience. It is important to find a BPO provider that can incorporate specific business rules and customize its system capabilities to align with the clients business needs. The technology must be scalable to quickly ingest new groups and business lines into the claims administration. A customizable and scalable solution can be provided to increase data accuracy with a technical infrastructure that provides 99.9-percent system availability.
Were better at managing the distribution of our workload, our overhead costs are down and our auto-adjudication volumes have climbed. - Director of Operations, TPA
Automating every step of the pre-adjudication cycle allows claims to be processed more efficiently and more accurately. As claim processing improves, auto-adjudication rates rise and the total cost per claim falls. Operational inefficiencies caused by error-prone human processes can be remedied. Leading BPO providers can outsource healthcare claims processing better, faster and more cost-effectively than any manual, in-house paper-based process. Modern providers are notably different from traditional outsourced labor and BPO solutions, because the claim-cleaning power is derived completely from automation. The powerful technology can: Eliminate error-prone human processes Guarantee increased pre-adjudication rates Increase claim payment accuracy Lower costs per claim.
A cleaner payment process is created by innovative automation technology that eliminates dirty data on the front end. The lower an organizations adjudication rate, the more advanced pre-adjudication technologies can help.
About BancTec
BancTec helps clients around the world simplify the process of managing their information. Founded in 1972, the company provides financial transaction automation and document management services for organizations seeking to drive efficiency in their financial and back-office processes. Operating 21 BPO centers in the United States and worldwide, BancTec utilizes a common technology platform to deliver reliability, security, and consistently high levels of performance. For further details, visit www.banctec.com