Claims Adjudication Services:

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 VeeInsure have continuously renewed contracts, enlarging the scope of work, with more complex and evolved processes. These include processes involving super/miscellaneous claims adjudication.

At VeeInsure we adjudicate payment using either our client's own payment system or we use our proprietary claims system. VeeInsure has substantial experience in insurance claims processing using a variety of claims management systems.

VeeInsure understands that this claims payment and repricing is a very difficult process. It for this reason we choose experts from amongst our experienced and proven team of claim processors. They go through rigorous training on the client's processes and subsequently develop proficiencies in a simulated environment. We are able to do this through our experience in education, managing several colleges for over 50 years - ( www.sonatech.ac.in) Our colleges have developed specialized courses on US healthcare and have created several case studies. We use our e-learning experience (www.sonaversity.org) in developing courseware based simulation where we create multi layer education processes.

This is just a glimpse of our adjudication process. For a fuller and more complete description do call: 1-877-794 95, or email us at:

Eligibility
Eligibility process involves several intricate processes, including 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 either our clients' or our own 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 from 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 VeeInsure. Our code review processors are trained in healthcare processes; 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 such processes decelerate the claims process during review, VeeInsure's approach ensures that the claims that can be approved go through the silo and the questionable claims alone are screened by doctors or physicians.

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.

Try the Vee experience.!! Its worth it. Please call us on 1-312-373-9346 or email at