Medical Insurance Claims Adjudication
Partner with VeeInsure to handle your claims adjudication process needs. VeeInsure has been adjudicating claims payments for Large Insurance Carriers and TPAs since 1999. Our claims adjudication capabilities and experience enable us to provide our clients with quantifiable gains in quality and operational efficiency. These are proven services and the clients of Vee have been delighted with Vee’s services that they have renewed contracts and given them
additional
complex processes.
Having processed 50 million transactions, Vee has gained indepth experience in claims processing. Our clients feel that this has given us a strong foundation and have further outsourced
process like
super/miscellaneous claims adjudication process to us.
At VeeInsure
we adjudicate
payment using our client’s payment system or we use our proprietary claims system. VeeInsure has substantial experience in processing claims using a variety of claims management systems.
VeeInsure understands that this claims payment and repricing is a very difficult process. It is for this reason we choose our team amongst our experienced and proven team of claim processors.
They go through a rigorous training on the claims adjudication process
. We believe in educating our adjudicators and then training them on simulated claims. We are able to do this through our experience in education (running several colleges ‘for over 50 years’ www.sonatech.ac.in) here we have courses on US healthcare and create case studies. We use our e-learning experience (www.sonaversity.org) in developing courseware based simulation where we create multi layer training process. Here the processor is tested in various areas and different situations and made to test his/her skill, knowledge, and expertise on the real life simulated claims.
This is a glimpse of our claims adjudication process. There are a plethora of points that Vee follow in the training, migration, processing and auditing process, we will be happy to share this over a email, call or in meeting with you do:
Call : 1-877-794 9514
Email us at:clientservices@veetechnologies.com
Eligibility
Eligibility process involves several intricate process and verification and judgment. For this reason VeeInsure identifies the patient to determine, if the 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
Sometimes, service providers submit multiple claims. VeeInsure identifies if the claim is a duplicate claim. We use clients/our proprietary near-duplicate matching algorithms to identify duplicate claims that were previously undetected. This process involves interactively capturing and checking the patient information against the claims history database provided by our client. The duplicate-check process criteria are customized for each client depending on the plan, process and the system.
Coding, Bundling, and Diagnosis Review
Using a knowledge base of clinical rules, VeeInsure’s overpayment prevention solution finds claims that should be bundled under a single, less expensive code, and detects clinically inappropriate diagnosis, incomplete entries, and irregularities in coding. A physician variance reporting tool is provided to illustrate paid claims, cost by provider and a summary of the reasons why the physician codes were different than his or her peers. It also illustrates the potential overpayments that may have been missed and provides the defense to the rules, so that savings can be maximized confidently.
This is a service that is unique to Vee, our code review processors are trained in healthcare processes plus they also have clinical knowledge to look at the genesis of the code. They are trained to look for minimizing the costs of the procedure.
The advantage here is that, whilst most of such processes will decelerate the process during the review process, process has 95% claims that are ok goes through the silo and the 5% of the questionable claims goes through people who have nursing, physicians or doctors who screen them
Hospital Detail Analysis
VeeInsure’s Hospital Analysis services provide an extensive analysis of both inpatient and outpatient hospital bills, resulting in a sound recommendation for services performed. The detail analysis formulae use Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC) as foundation components for calculating appropriate reimbursements, and then apply another formula to account for consumption of resources, severity of the claim and geographic pricing factors.
Benefit Determination Adjudication
VeeInsure adjudicates the valid claims amount considering complex rule sets. (E.g. 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, VeeInsure’s configurable claim editing software validates each claim
and further 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.
Vee will be happy to answer your questions and discuss over a call. Please contact us on 1-877-794-9514 or email at 
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