Healthcare Claims Processing

Business Challenge:

The two major issues in the heavily regulated health claim industry are service and costs. The health insurance industry is required by law to service their customers. Claims must be paid or denied within regulated timeframes. When claims are not processed within those time limits, expensive penalties are invoked. Service timelines are adversely impacted when additional medical records are required. Claim files are pended until requested documents arrive; and documents must be manually matched to the existing file. Complex claims are more likely to be misplaced because they must be routed to medical review specialists, and quality control. As files are sent from one department to the next, it is more difficult to meet service standards, and keep track of processing timeframes. Paper files compound service inefficiencies because documents and files are lost or delayed in routing. Claims service is expensive. When information isn't available to insured's and providers, it causes repeated phone calls, re-submission of claims, and additional work. The service inefficiencies inherent to paper files generate costs and expensive regulatory penalties.

Business Solution:

The Web, document management, and workflow systems present new opportunities for insurers to increase service levels, manage claims processes, and eliminate costs. Web access dramatically reduces costs because it encourages self-service. Web-enabled document management systems give simultaneous access to documents and claims status information to providers, claims reps. and claimants. When documents are held in an electronic repository, service levels increase because claim files are never lost and documents are never misplaced. The need to request a duplicate claim submission is eliminated. Costs are eliminated as workflow takes over unnecessary manual tasks. Workflow manages the payment of claims within regulated timeframes. Expensive penalties are avoided. As workflow guides complex claims from department to department, it automatically gathers information for proof-of-compliance reporting. The web, electronic document repositories and automated workflow systems combine to reduce costs, and assure compliance, and increase service levels. Where is the Market? Insurance Companies Third Party Administrators - TPA's Preferred Provider Organizations - PPO's Health Maintenance Organizations - HMO's

Where is the Market?

• Insurance Companies
• Third Party Administrators - TPA's
• Preferred Provider Organizations - PPO's
• Health Maintenance Organizations - HMO's