Claims Adjudication Optimization

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Streamlining the claims adjudication process

From selection and implementation of new platforms to upgrades and optimization of existing operations, we can help streamline the process. We offer clients deep and unique expertise with system integrations, data analytics, development and refinement of internal controls, regulatory guidelines impacting payment integrity, as well as common claim scrubber pitfalls that contribute to erroneous payments. This includes audit and assessment of third-party administrator (TPA) and pharmacy benefit management (PBM) partners. We also provide strategic guidance to aid in the development, deployment and optimization of value-based care models driving the need for greater collaboration and transparency between payers and providers. Our experts effectively and efficiently identify and provide solutions to remedy issues contributing to waste in the claims adjudication process - aligning the people, process and technology required for peak performance.

Solutions:

Strategic Planning - healthcare reform is a driving force for increased innovation between payers and providers. Reducing cost and improving the quality of care requires strategic planning, execution and continuous monitoring to ensure profitability under new payment models. We provide thought leadership to design, implement and measure outcomes to maximize value-based care and fee-for-service product lines.
Selection of New Technology - Whether drafting a request for proposal (RFP) or planning for an implementation, we can help manage the process of onboarding new technology. We can help evaluate vendors as well as features and functions to ensure the best fit.
Platform Upgrades - Our advisors can assist in the assessment and identification of downstream ramifications associated with version changes and upgrades to help safeguard against unintended changes that can hinder workflows.
Data Analytics - We can assist in the development and deployment of analytic tools, such as dashboards to consolidate key performance indicators, even merging data from disparate systems.
Claims Adjudication Expertise - We have deep and unique expertise with internal controls, compliance and a wealth of experience with what commonly contributes to erroneous payments, delays and denials.
TPA & PBM Review - We offer a proactive approach to reduce unnecessary costs related to healthcare administration by providing in-depth assessment of TPA and PBM operations. We ensure the most timely and accurate processing of claims on our clients' behalf.
Internal Control Testing - We conduct assessments of claims adjudication processes, including verification of accurate and timely claim submission, appropriate claim edits, payment and reconciliation.
Policy and Procedure Assessment - We focus on review of policies against regulatory requirements, industry standard and best practice. We work with key stakeholders throughout the claims adjudication processes to identify variances between documented policy and actual performance.