Driving Transformation with Reductions in Denials and Turnaround Time

In the post-reform marketplace, healthcare payers are focused on gaining efficiencies by improving claims accuracy, reducing turnaround times, and more efficiently managing processing. Claims operations leadership struggles to effectively transform operations to perform at the highest level of compliance and quality standards while also focusing on cost-containment. As the Affordable Care Act continues to take effect, these particular challenges and opportunities will be more prevalent.

At HGS, we pride ourselves in working closely with our payer clients to enhance their competitive position, improve client satisfaction, facilitate communication across multiple channels, and deliver positive and sustainable results.

How We Do It

Our claims administration services comprise adjudication, research and overpayment recovery and denial management. These services include:

  • Interface with clients' auto adjudication to effectively provide manual adjudication by industry professionals with experience in re-pricing/network review, edit resolution, and pre-paid and other audits
  • Financial recovery, processing of claims overpayments
  • Scanning of fulfillment services documents
  • Review of any flagged historical claims for accuracy and investigation of claims for potential overpayments
  • Claims re-pricing that focuses on claims adjustments when working with non-par or out-of-network providers
  • Researching of claims for medical appropriateness

Along with our Claims Benefits Management Operations, HGS also provides extensive Clinical Operations, Benefit Configuration, Enrollment, and Fulfillment processes among other services.

Our Value

Our solution presents this measurable value:

  • Impact to operational metrics, with 99.50% claims accuracy (above industry average of 92.9%, according to the American Medical Association [AMA]).
  • Vast resources including more than 90 processes and 400+ sub processes.
  • Impact to efficiencies, such as significant reductions across three critical metrics: claims denials, handle time, and turnaround time.
  • Cost containment
  • Customer care focus

"As a result of HGS's informative monthly reporting, we were able to address areas of opportunity and prevent future accounts from aging."

Leading U.S. Health System

99.50% claims accuracy (above industry average of 92.9%, according to the American Medical Association [AMA]).

15-Year
Relationships
1/2
of Top Healthcare Payers Supported
10,000
Healthcare Professionals
Serving Members on behalf of Payers and Providers
Industry-Leading Compliance
100% Client Retention