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 The process for adjudicating medical claims has grown increasingly difficult in recent years. At the same time, many health care organizations have entered risk sharing agreements and assumed claims management responsibilities.
HORNE Health Care Services has developed a diagnostic examination of the claims paying process. This special procedure audit, which can be modified to your own specific needs and interest, is designed to test the following areas:
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Accurate handling of claims from the entry point into the organization through the termination point (payment, denial, appeal, etc.).
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Proper administration of reinsurance, coordination of benefits and subrogation.
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Eligibility management.
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Proper calculation of incurred but not reported claims (IBNR).
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Appropriate internal controls related to the claims payment process.
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Effectiveness and capacity of claims payment system.
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Effective support of contracted providers by the customer service function.
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Whether you are performing these functions internally or using a third party, an independent review of this process can be very valuable. HORNE Health Care Services has the experience to analyze your claims adjudication process.
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