Client Portals

What Is Adjudication?

clock and cogs graphic representing time spent in claims adjudication process

Did you know that the word “adjudication” is used in multiple industries and carries different meanings for those industries?

If you work in the healthcare payer industry, then claims adjudication and auto-adjudication are terms that you should know very well. But just in case you need a quick reminder, adjudication is the process of reviewing and paying, or denying, claims that have been submitted by a healthcare provider.

When you go to a medical provider and present your insurance card, the staff will record the insurance information, including your policy number. Once you receive the services from the provider, they will then submit the claim to the insurance company. Thus begins the long process that is claims adjudication.

When a TPA, Health Plan, PPO, or any other healthcare payer that handles claims receives a claim from a provider, they will match the insurance number to the patient. This is quick and easy because that policy number is unique to the plan and patient. The challenging part is matching the claims to the correct providers.

Many claims are entered manually, leaving room for human error. Common errors that can occur are:

  • Providers names spelled wrong / different from what the payer has listed
  • Location address inaccurate – some providers may work in different locations and types of facilities (i.e. OBGYNs work in both offices and hospitals) or have moved
  • Incorrect specialty codes for the services, the providers tax identification numbers, etc.

After all the claims details are entered into the claims payment system and validated, the payer must determine the amount needed to be paid to the provider based on their Network and Fee Schedules.  The check is then written and mailed to the provider (hopefully at the appropriate location), completing the adjudication process.

Many healthcare payers have claims payment systems in place that make this process simpler and quicker, with little human involvement. This is an all-around more efficient and cost effective solution called called auto-adjudication. Unfortunately, if information doesn’t match correctly in the system, the claims will go into a “provider not found” queue, which requires a process of manual human intervention.

For over 25 years, BASELoad has been working to help TPAs, PPO, Health Plans, and other healthcare payers increase their auto-adjudication rate with services that clean, validate, and fulfill medical provider information. Through our custom EDI Provider Matching service, SureHit, we have increased payers’ auto-adjudication rates. SureHit is currently operating at a 98-99% provider matching accuracy and has been proven to reduce payers’ bottom lines.

Wouldn’t it be nice to eliminate the headache of bad provider data and “provider not found” queues? Wouldn’t you like to bring on new business without having to increase resources and overhead? With BASELoad, you no longer need someone there to manually match providers to claims. Also, with a quicker process and fund disbursement, provider satisfaction rates are sure to increase.

If these issues are all too familiar and you would like to increase your auto-adjudication rate, reduce your bottom line, and learn more about BASELoad and our services, give us a call at (704) 424-9889 or email us at sales@baseload.com.