Health Plan Claims Adjudication

Temporary Staffing for Health Plan

In an environment faced with funding gaps and workforce shortages, healthcare facilities of all sizes occasionally need assistance with short- or long-term healthcare staffing. From nurse staffing and physician staffing to allied clinician and health plan staffing and recruiting, Essential Healthcare Solutions offers a broad spectrum of healthcare staffing services often found in multiple medical staffing agencies – all rolled into one single strategic business partner. Are you in need of direct placement or per diem healthcare staffing services? Looking to fill an immediate opening, or need full-time assistance managing all or part of your healthcare recruitment processes? Whatever the situation, trust us to deliver the specific skills and expertise you need for long-term success in your healthcare staffing.

Claims Adjudication

Adjudication is the process involved in the disposition of claims…from paying, denying to rejecting a medical claim…all for valid reasons based on a set of rules set by the payer.

Adjudication involves a deep understanding of the payment processes used by the commercial Insurers, Medicare and Medicaid to reimburse providers for medical care provided to the beneficiaries of the Insurance Companies or Institutions

The adjudication team starts with a thorough comprehension of the payer’s software, the rules, the reimbursement structure, the rationale, the exceptions, the pre conditions and the formularies.

In most cases the software typically auto adjudicates over 50% of the claims.

Essential Healthcare Solutions will handle all the claims that have been rejected by the software for a multitude of reasons and work with providing a quick disposition for claims that come through the system.

Essential Healthcare Solutions in the process, will also create a knowledge base that will enable the new rules to be incorporated in the (next) iteration of the software’s edits to enable auto adjudication.

Some of the specific tasks done by Essential Healthcare Solutions includes:

  • In the case of non-digital forms, Netmark verifies each field entered twice for accuracy
  • For Medicare where members change plans frequently, eligibility determination is an important first step
  • Eligibility determination also creates the right pathway to adjudication entitlement
  • Primary insurance verification
  • Timely filing limit issues
  • Determination of participating provider status
  • Checking Prior authorization rules and status prior to processing
  • Checking status of duplicate or corrected claims
  • Identifying and isolating data elements from raw data claims
  • Calculating valid claim amount
  • Determination of DRG
  • Understanding managed care rates per diem including cap rates
  • Determination of correct allowable
  • Accurately calculating co pay and coinsurance details per benefit plan
  • Use of appropriate remark/adjustment codes
  • Establishing medical service provider type
  • Validating data against adjudicating engine
  • Committing fully adjudicated claims

Provider Relations

The purpose of Provider Relations is to provide exceptional customer service by supporting our Claims team and responding to inquiries from providers. Essential Provider Relations Representatives answer provider inquiries regarding verification of benefits and Claims status.  We also provide a variety of other solutions to support the company. Some of these solutions include: entering precertifications into the claims processing system, working miscellaneous claims queues, processing pharmacy claims, sending out correspondence, outbound provider call projects, and reviewing claims spreadsheets and plan documents. Our utilization of necessary resources help providers navigate systems efficiently to accurately verify eligibility and provide verification of benefits. Assisting providers in getting set up and utilizing all neccessary tools promote a positive and professional attitude. Our team will work with members of staff on identifying process improvements.

Call Center

We started working with healthcare clients back in the eighties, and to say things have changed in the meantime would be an understatement. The field of healthcare changes rapidly, and our healthcare call center experience gives us the ability to readily adapt.

If it’s your first time contemplating outsourcing, we will walk you through the process. If you’re looking to make a change with a current vendor we can assist with the transition. Everything we offer can be customized to your needs. We can join you in supporting your call volume or we can even take all of your calls. Now you can expand your healthcare customer service hours to evenings and weekends and we can also be a part of any disaster recovery plan you may need to implement.

We are completely U.S. owned and operated. We have call centers all over the country as well as an experienced management team – many of them started on the phones supporting clients just like you.  

Credentialing

Provider Credentialing and Clinical Privilege management are cumbersome, but necessary, tasks for the practice of medicine. Hospitals are obliged to guarantee their providers have the necessary education and training to diagnose and treat their patients, thus assuring optimal care is provided on behalf of the hospital.

Payors also want to make sure their providers are indeed qualified to provide that care given the complexities of diseases and the regulatory system

Provider competence and performance are constantly subject to reviews and evaluations by the Joint Commission of Medical Staff. New technologies necessitate these providers are trained and educated on new methods and machines. Apart from the initial review of educational and training competencies, there is also a need to continue evaluations of the providers periodically to assure the highest quality of care and outcomes.

Essential Healthcare Solutions can help you with the challenges of initial credentialing as well as the all-important maintenance of up to date evaluation and compliance.