Claims processing represents one of the highest administrative costs in the US Health Plans industry. Regardless of decades of investment in improving first pass auto-adjudication; paper claims, manual processing, and claim errors remain one of the greatest sources of loss, costing Health Plans billions of dollars every year. As the number of covered individuals rises and the requirements of the healthcare industry change constantly, more efficient processes, smarter analysis, and the most accurate data possible are necessary to provide the quality and value the market demands.
Firstsource’s healthcare claims processing and adjudication solutions allow you to provide that quality and value. Our proprietary workflow technology, skilled adjudicators, and automated audit processes help reduce turnaround time (TAT), increase processing quality and accuracy, and reduce backlogs—with no additional capital investment required. By optimizing existing procedures, automating analysis and applying a secure digital workflow, Firstsource helps to improve your operations, reduce costs, and increase client satisfaction from claims intake and processing to final adjudication and payment.
Backlogs lead to costly delays, financial penalties, and member and provider dissatisfaction. Our high-performance imaging capabilities, automated workflow, and highly trained professionals enable us to convert existing backlogs and keep future backlogs to a minimum.
Firstsource’s experienced agents can supplement your staff during periods of high traffic, providing support with even the most complex aspects of claims adjudication, including claims re-pricing according to your established provider discounts.
Firstsource supports a wide variety of claims across multiple plan types, processing platforms, and fund accounts such as FSAs, reimbursements, deductibles, co-pays, and more.
Expert pre-adjudication leads to faster claims processing with fewer errors. Firstsource’s verification service ensure that claims data, member and provider data, and coding are accurate. To minimize fraud and error, Firstsource’s associates reconcile claim data with codes, dates, descriptions, and pertinent line items. Our automated systems match claim data with member and provider files and process them according to your customized rule sets.
Firstsource also identifies discrepancies in coding and medical data—such as mutually exclusive procedures, modifiers, and conflicting dates—and makes corrections according to all applicable guidelines and conventions.
Firstsource’s claims adjudication solutions provide analysis and adjustments to support the decision-making process. Our analysts examine fee-for-service medical 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, we review associated data to identify overlaps, make corrections, and determine which information should be discarded or retained when duplicates are merged. When claims are denied, Firstsource assesses root causes, identifies controllable errors, and communicates with necessary parties.
Additionally, our automated workflow allows us to manage the appeals process quickly and efficiently for prompt review and response.
One of America’s leading self-insured, not-for-profit associations providing health and dental plans to federal employees and their families needed immediate additional resources in customer service and claims adjudication to facilitate business growth.
Firstsource provided additional customer service resources and claims examiners to support immediate business requirements, as well as delivered fully trained resources within 90 days, including enhanced First Call Resolution (FCR) through highly skilled and dedicated customer service agents.
TAT and inventory management were measurably improved by deploying highly skilled claims examiners experienced in managing complex claims and adjustments. Firstsource delivered a 98% claims accuracy rate and a 30-second response rate to 85% of incoming calls.
Our clients include 12 of the top 20 Health Plans nationwide
Our solutions are backed by Robotic Process Automation, advanced analytics and more
With our 20+ years' experience in the field, you'll know your customers are in good hands