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Claims Adjudication & Automation

In the ever-evolving healthcare industry, efficient claims processing is critical for both payers and providers. Our Claims Adjudication & Automation solutions are designed to streamline the entire lifecycle of claims management. By leveraging cutting-edge technology, we ensure accuracy, compliance, and speed, enabling organizations to reduce costs and improve outcomes. Whether it's auto adjudication, audit and compliance, or provider dispute resolution, our solutions are tailored to meet the unique needs of healthcare organizations.

Auto Adjudication Scripts

  • Designed and developed auto adjudication scripts for applying business rules in either batch or real-time mode.

  • Achieved 80% auto adjudication at multiple client sites, significantly reducing manual intervention and improving operational efficiency.

Audit and Compliance

  • Created claims payment integrity checks including duplicate checks, leveraging a 16-pass algorithm to detect “corrections” vs. “duplicates” vs. “re-submissions.”

  • Developed automated jobs to flag claims for manual audit and re-audit, ensuring payment or processing compliance.

  • Designed robust audit applications and processes to streamline compliance efforts and enhance accuracy.

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Bundling, Grouping, and Pricing

  • Implemented bundling processes for inpatient, outpatient, and ASC claims before or after claim loading.

  • Integrated pricing algorithms and logic to ensure claims are grouped and priced accurately, adhering to regulatory and payer guidelines.

  • Interfaced with leading tools such as 3M, Clinical Coding Expert, and MicroDyn EncoderPlus to enhance claims grouping and pricing.

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Document Management

  • Automated medical records requests and developed systems for issuing automated approval or denial letters.

  • Enhanced post-decision activities by automating processes such as EFT (Electronic Funds Transfer) and EOB (Explanation of Benefits) generation.

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Provider Dispute Resolution

  • Handled appeals, re-pricing, and payment adjustments with a compliant communication framework to meet regulatory turnaround times.

  • Expertise in managing peer-to-peer reviews, reconsiderations, and other post-decision activities from a systems, compliance, and process perspective.

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Pre-Adjudication Enhancements

  • Introduced advanced data validation checks before claim loading to reduce errors in the adjudication process.

  • Designed real-time eligibility verification systems to confirm patient coverage and prevent claim rejections.

  • Automated the identification of incomplete or inaccurate claims for pre-processing corrections.

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Advanced Analytics & Insights

  • Leveraged predictive analytics to identify trends and anomalies in claim processing.

  • Built machine learning models to predict claim outcomes and recommend corrective actions.

  • Provided clients with actionable insights through customized dashboards and reports.

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Client Success Stories

  • Create and Store Rules in Azure Blob Storage

  • Streamlined dispute resolution processes for a national provider network, reducing turnaround time by 50%.

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