The insurance company processes the claims. The insurance company has medical directors review the claims and evaluate their validity for payment using rubrics for patient eligibility, provider credentials, and medical necessity. Approved claims are reimbursed for a certain percentage of the billed services. These rates are pre-negotiated between the health care provider and the insurance company. Failed claims are rejected and notice is sent to provider. Most commonly, rejected claims are returned to provide in the form of (Explanation of Benefits) EOB or Remittance Advice. Upon receiving the rejection message the provider or the medical billing company must decipher the message, reconcile it with the original claim, make required corrections and resubmit the claim. This exchange of claims and rejections may be repeated multiple times until a claim is paid in full, or the provider relents and accepts an incomplete reimbursement.
As a payer organization, it is essential for you to augment your health insurance claims processing process structure and reduce operating costs. Healthcare claims processing outsourcing and accuracy in health insurance claims processing are the key elements to improving your turn-around time and claims output.
Structured Concepts offers a convergence of these factors through high potential segments in healthcare claims processing outsourcing such as medical billing and coding, transcription and health insurance claims processing. Structured Concepts has been a pioneer in the claims processing outsourcing. Structured Concepts has proven demonstratable experience in offering Insurance Claims Processing services. The key attraction for our customers has been our quality and the turnaround time. Our teams operatek 24×7 and are able to compress the Medical Claims Processing cycle. We have experienced professionals who do claims and health plans processing and analysis leading to claim validation and benefits assignment. Our experience has given us the knowledge and credentials to take us value added areas in claim processing.
We mark and manage core processing cost centers and generate considerable financial savings for your organization. Our health insurance claims processing services are driven by transactional efficiency. Our services help you achieve maximum automation of your manual claims resolution processes. They support new products and services, leverage your existing legacy system infrastructure, and also comply with the HIPAA mandated regulations for administrative simplification.
