Maximizing Returns on Your Claims Auto-Adjudication Efforts: A Step-by-Step Guide for TPAs

by | Jan 26, 2022 | Healthcare

Health insurance form that will go through claims auto-adjudication for TPAs

The percentage of businesses that turn to third-party administrator (TPA) services grows every year. A TPA usually serves as an intermediary between the employer who covers the employee health insurance and insurance companies and performs administrative functions, often utilizing sophisticated data processing tools to help with various tasks, including claims auto-adjudication. But what are the advanced technology tools that can facilitate the process of claims auto adjudication for TPAs?

Let’s get into the details.

Key Takeaways:
  • Modern technology greatly facilitates all processes related to data processing in healthcare revenue cycle management.
  • TPAs ought to offer their customers much more than just standard consulting on getting a regular claims resolution. It is essential to provide the best and fastest methods of resolving customer claims to stay on top.
  • Auto-adjudication is the ultimate solution for fast, error-free insurance claim processing and health insurance benefits compensation.

Which Companies Could Benefit from Using TPA Services?

The premium health insurance plans take up the lion’s share of any company’s budget, whether it’s a small business or a large-scale enterprise. This is why self-funded health coverage plans are growing in popularity, as this type of insurance helps employers control rising health care costs. Besides, many healthcare costs are misspent, so employers are taking steps to eliminate these costs through self-funding, which is when a TPA comes into play. 

When companies switch from a traditional full-coverage health insurance policy to a self-funded health plan, a TPA provides adequate healthcare data management by:

  • Handling full data validation for the various types of health insurance coverage
  • Controlling providing service to clientele on a long-term basis
  • Administering health insurance plans

4 Benefits a TPA Should Offer Its Clientele to Improve Claims Auto-Adjudication Returns

TPA services used by businesses and individuals can positively impact the medical claim resolution. The most significant benefits of using TPA services include:

1. A Customer-Oriented Approach

A customized approach involves developing a personalized health insurance plan, including the requirements of the financial insurance sponsor.

Unlike insurance companies that mainly stick to the one-size-fits-all strategy and offer standard insurance plans to all employees, a TPA evaluates and analyzes all possible benefits for a particular employee to determine the best coverage. 

2. A Significant Cost Reduction

To accomplish cost reduction for insurance plans, a TPA should:

  • Monitor the company’s assets, expenses, and revenues
  • Find the most fitting financial solution
  • Offer the optimal insurance policy

Evaluating the financial capabilities of a particular business and offering the most flexible and favorable insurance terms based on the business owner’s financial assets can also help reduce costs. It’s also worth mentioning that a business owner who refuses to invest in a health insurance plan subsequently pays a higher price. 

3. Flexibility and Faster Claim Processing 

For a smoother health data exchange between any healthcare facility, business, and insurance company, TPAs should use top-notch healthcare master data management (MDM) systems to:

  • Improve the efficiency of data governance in healthcare
  • Fully automate all processes
  • Get the desired results in the shortest period

4. The Application of Modern Technological Tools

Medical organizations often implement modern utilities to interact more effectively with patients and provide information to insurance companies. Adopting modern technology has undoubtedly made counseling, diagnosis, and treatment processes more efficient. 

Traditional Claim Processing vs. Automated Claim Processing
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A top-notch medical information system allows identifying and planning all resources of a medical institution with specialized software, computer equipment, necessary medical equipment, and means of communication. It supports treatment-diagnostic, financial, administrative, accounting, and service activities to provide quality medical services to patients. 

Why Is Medical Claims Auto-Adjudication Necessary for Businesses and TPAs?

Competent TPAs strive to use advanced technology and tools for claims processing. Thus, claim auto-adjudication is often implemented to facilitate claim management and reduce health insurance costs in the medical lifecycle billing process.

Medical billing lifecycle
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By incorporating the latest technology, TPAs can:

  • Ensure full compliance with benefits rules when reviewing claims compared to manual adjudication. Manual claim adjudication requires manual data entry to submit the necessary information to insurance companies, which entails some inaccuracies and can delay claim processing.
  • Apply auto-adjudication that can significantly reduce the time required to process a claim. With innovative technology, the system can adapt to a rapidly changing environment and keep track of all reference data management, including the information about the patient, the insurance company, and the medical facility where the patient was treated.

Check all information in the healthcare data management cycle. Checking healthcare data for accuracy and relevance with no human intervention helps avoid any mistakes that could cause a delay in the insurance payment process and automatically approve, deny, or modify a claim.



Coperor E-MDM Platform Can Help Improve Auto-Adjudication Processes

To reduce worst-case scenarios, both medical facilities and businesses need the professional advice of experienced healthcare consultants who clearly understand the right health insurance plans for businesses and a reliable system to keep track of all insureds’ medical records.

Coperor by Gaine is ready to take care of all the insurance-related challenges. With a focus on an individual approach to every client or business, our top-notch MDM platform is one of the most proven systems used for cooperation with SMEs and healthcare insurance companies. We integrate third-party reference data sources (the USPS for address verification, LexisNexis Payor and Patient data, NPPES, credentialing data, etc.) and provide additional reference data tracking for seamless operations.

Our experts can offer strong management of all the insurance processes from scratch and provide further support in patient engagement solutions, thereby allowing medical institutions to focus on their core business. So, rest assured, your insurance claims are in good hands with Gaine.

Ready to see what we help you with? Get in touch with us by phone, email, or fill out an online contact form today!


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