Payers succeed or fail on the speed and accuracy of their claims process.
Are you set up to succeed?
Changing regulations, increased demand, and new systems are making the claims process more challenging—even as demands rise for quick response and reduced cost. Old processes simply aren’t enough to function effectively in the new healthcare environment. With industry-leading technology, proprietary systems and processes, secure and centralized data management, and highly trained and experienced staff, Firstsource offers the solutions to make that most essential of functions—establishing end-to-end operations, optimizing existing processes, and providing our own assistance and expertise for claims processing that helps our clients thrive.
Helping the lifeblood of your organization to flow smoothly
Backlog Conversion and Reduction Support
Backlogs result in costly delays, financial penalties, and member and provider dissatisfaction. With new regulations and vastly increased data volume accompanying the recent shift to ICD-10, payers are increasingly at risk of falling behind. Firstsource’s high-performance imaging capabilities and proprietary systems enable us to convert your existing backlogs and keep future backlogs to a minimum. Our team of highly trained and experienced professionals supplements or complements your internal resources or simply steps in to augment your team during times of high volume.
Payment Integrity/Payment Validation
Using data mining and analytics, we identify erroneous or fraudulent claims, detect wasteful practices that can interfere with the integrity of payments, and ensure that payment amounts are accurate based on provider, plan, and eligibility. But we don’t just attend to the quality of your payments—we also put our automated systems and deep industry knowledge to use optimizing your claims process for greater efficiency and accuracy within your operations.
Coordination of Benefits
Firstsource’s coordination of benefits services help you avoid costly overpayments, duplicate payments, and processing delays when multiple plans or payers, public or private, are involved.
We manage the administrative complexities of claims re-pricing on your behalf, receiving the paper or electronic claims, making the adjustments ourselves according to your established provider discounts, and forwarding them to you for further processing.
Peak Period Overflow Support
Our trained agents are capable of supplementing your own staff when volume is high, whether through administrative assistance, customer service, document management, analytics, or even the more complex aspects of claims adjudication, providing scalable, on-demand services when and where you need them most.
Cleaner data through expert pre-adjudication
Service Line Verification
We reconcile claims data with codes, dates, descriptions, and pertinent line items to minimize fraud and error and facilitate adjudication.
Member and Provider Verification
Automated and individualized systems match claims data with member and provider files and process them according to your customized rule-sets to enhance accuracy throughout the adjudication process.
Correct Coding Edits
Firstsource identifies discrepancies in codes and medical data—mutually exclusive procedures, modifiers, invalid codes, conflicting dates—and makes corrections to ensure that coding complies with all applicable guidelines and conventions.
Strong analysis for strong decisions
When inconsistences appear in in claims such that the amount billed isn’t the amount that should be paid, Firstsource makes necessary adjustments and provides itemized justification for the change.
In the case of bundled payments, Firstsource examines fee-for-service claims in the context of identified bundles—both preconfigured and customized—to ensure that members receive the highest quality of service and total cost of care remains within reasonable limits for accurate reimbursement.
When duplicates are encountered, Firstsource reviews associated data to identify overlaps, make corrections, and determine which information should be discarded or retained when the duplicates are merged.
Denials Management/Appeals Processing
When claims are rejected or denied, Firstsource assesses root cause, identifies controllable errors and aggregate patterns, and communicates with necessary parties. In cases of appeals, our automated workflow enables us to manage the appeals process quickly and efficiently for prompt review and response.