services

Claims Adjudication

Claims Adjudication

We Are On Your Side

Since 2000, large insurance carriers and TPAs in the U.S. have entrusted their claims adjudication processing to Vee Technologies USA. Our claims adjudication capabilities and experience enable us to provide our clients with measurable gains in quality and operational efficiency. Over the past six years, we have processed over 50 million transactions and have acquired an in-depth experience in insurance claims processing.

You understand that claims payment and repricing is a very difficult process, and that results are better garnered when these are handled by experts dealing with adjudication day in and day out.  It is for that exact reason that we build our Insurance Payor Services team based on industry experience and proven results. Our team goes through a rigorous training on the claims adjudication process. We believe in educating our adjudicators and then training them on simulated claims so they can adjudicate payments from day one of a project using our client’s payment system or our own proprietary claims system.

Eligibility
The eligibility process involves several intricate processes, verification and judgment to determine if an individual is covered by an active policy or plan. This process involves interactively capturing and checking the patient information against the eligibility database.

Duplicate Claims Check
It’s a fact of life!  Whether intentional or not, service providers sometimes submit multiple claims. Let us help to identify duplicate claims. We use both our own proprietary system and client-based software to find matching algorithms and identify duplicate claims that were previously undetected. This process involves interactively capturing and checking patient data against claims history databases. The duplicate-check process criteria are customized for each client depending on the plan, process, and the system.

Coding, Bundling & Diagnosis: A Vee Process Unlike Any Other

Want to save even more?  Our overpayment prevention system:

  • Finds claims that should be bundled under a single less expensive code
  • Detects clinically inappropriate diagnosis, incomplete entries, and irregularities in coding

Granted 95% of claims are okay to go through the silo, we find that the remaining 5% are “questionable claims” that require screening by nurses, physicians, or doctors.  A physician variance reporting tool is provided to illustrate paid claims, cost by providers, and a summary of the reasons why the physician codes were different from his or her peers. It also illustrates the potential overpayments that may have been missed and provides a solid defense to the rules, confidently maximizing savings. This service is unique to Vee Technologies USA and our processors have the clinical knowledge to look at the genesis of the code to minimize the costs of the procedure.

Hospital Detail Analysis
Our hospital analysis services provide an extensive examination of both inpatient and outpatient hospital bills. The detail analysis formula uses Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC) as the foundation components for calculating appropriate reimbursements.

Benefit Determination Adjudication
Let us adjudicate the valid amount for each and every claim.  We take into consideration all sets of rules, for example benefits for the first $10,000 in covered expenses - after deductibles - will be reduced by 50% for not pre-certifying hospital admissions, depending on the plan and the structure.

Rules-Based Edits
Using a knowledge base of customer specified and industry standard rules, our configurable claim editing software validates each claim and further evaluates each field in a claim to eliminate or flag errors prior to adjudication. Claims with missing or incorrect information can be selectively returned or routed based on the client’s direction.