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American Healthcare

The U.S. Healthcare segment is on the move when it comes to outsourcing of healthcare insurance processes. Post reform, an upward trend is observed in the market. The development of information technology has only eased the process of outsourcing for Healthcare industry. Some of the major technology outsourced by US companies are computerized physician order entry (CPOE), electronic medical records (EMRs), inbound voice response systems (IVRs), network and data management, automated claims processing, regulated compliance monitoring, application maintenance, system integration, application development, product reengineering/maintenance, HIPAA consulting, and e-business initiatives. In the BPO segment, common work includes insurance claims processing, adjudication, receivables management, billing and coding services, radiology reporting, and transcription services.

India is miles ahead of othercountries when it comes to its popularity as an offshoring destination. Around 75 percent of US healthcare companies outsource some work or the other to other nations. Medical transcription (which involves electronic capturing of patient information and converting it to a useable format) is mostly outsourced in Healthcare insurance sector. There are various reasons why U.S. healthcare organizations are looking to outsource. The most important being shortage of qualified staff in key positions such as nurses and coders.

We generally come across three types of outsourcing model:

  • Cost-based model where the entire functions or projects are given to vendor based in another country or location. Here the main aim is to cut labor cost. Healthcare providers generally follow this model of outsourcing.
  • Business Transformation Outsourcing where the outsourcer is more involved with the business as opposed to merely few specific functions. Here, the involvement is much greater in easing the business operation. In other word, the outsourcer becomes an integral component of the entire business.
  • Business Process Outsourcing where the entire business unit, process, sales, or production function is outsourced to a foreign player. These models helps in maintaining a continuous work schedule by having teams in various time zones and expand sales or services into a different geographic location.

Enrollment & Dis-enrollment:

Enrollment is basically registering oneself for health insurance policy. Different policies have different clauses and guidelines for enrollment. For joining a Medicare Advantage (MA) plan, one must have Medicare Parts A andB. The Part B premium will continue to be taken out of Social Security or Railroad Retirement benefits check, unless one is enrolled in a Medicare Savings Program (MSP) or have full Medi-Cal or Medi-Cal with a share of cost (SOC) under $500. People cannot be denied enrollment in an MA plan due to a pre-existing condition, unless someone has an end-stage renal disease (ESRD) i.e. permanent kidney failure.


In general, people aged 65 years or older and are legal residents of the United States for at least 5 years are eligible for Medicare. People with disabilities under 65 may also be eligible if they receive Social Security Disability Insurance (SSDI) benefits. Specific medical conditions may also help people become eligible to enroll in Medicare. People who are 65 and older must pay a monthly premium to remain enrolled in Medicare if they or their spouse have not paid Medicare taxes over the course of 10 years while working.

People with disabilities who receive SSDI are also eligible for Medicare while they continue to receive SSDI payments; they lose eligibility for Medicare based on disability if they stop receiving SSDI. The 24 month exclusion means that people who become disabled must wait 2 years before receiving government medical insurance, unless they have one of the listed diseases or they are eligible for Medicaid.

Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a certain income, Medicaid will pay the beneficiaries’ Part B premium for them (most beneficiaries have worked long enoughand have no Part A premium), and also pay for any drugs that are not covered by Part D.

HealthCare Claims:

Medicare Advantage claim is the actual application for benefits provided by the health insurance company. Policy holders must first file a claim before any money or service deemed in the policy document is availed. It can be disbursed to the hospital. The insurance company may or may not approve the claim based on their own assessment of the circumstances.

Claims Adjudication:

This refers to the determination of the insurer’s payment or financial responsibility, after the member’s insurance benefits are applied to a medical claim. Some of the claims administration includes Medical, Prescription, Dental, Vision and Disability. Claims adjudication provides management of transactional back office services. Also performs high-end services for the insurance, finance & accounting, banking, mortgage and healthcare industries. The adjudicationprocess consists of receiving a claim from an insured person andthen utilizing software to process the claimsand make a decision or doing so manually. If it’s done automatically using software or a web-based subscription, the claim process is called auto-adjudication. Automating claimsoften improves efficiency and reduces expenses required for manual claimsadjudication. Many claimsare submitted on paper and are processed manually by insurance workers.

Many insurance companies take advantage of auto-adjudicationas a method of managing the large number of claimsthat has to be processed on a regular basis. Claimsare submitted electronically in most cases, although paper claimsare still an option, and the information is entered into software that reviews the claims. The software checks for errors, eligibility requirements, and deductible payments, and some software programs will even check for fraud. If the claim meets the insurance requirements, then it will be paid. When the claim fails the auto-adjudicationprocess, then it can be denied or sent to an insurance examiner to review the claim manually.

After the claimsadjudicationprocess is complete, the insurance company often sends a letter to the person filing the claim describing the outcome. The letter, which is sometimes referred to as remittance advice, includes a statement as to whether the claim was denied or approved. If the company denied the claim, it has to provide an explanation for the reason why under regional laws. The company also often sends an explanation of benefits that includes detailed information about how each service included in the claim was settled. Insurance companies will then send out payments to the providers if the claimsare approved or to the provider’s billing service.

The insurance company might only make a partial payment to the provider as a result of claimsadjudication. Insurance companies are often required by law to provide an explanation as to the reason why only partial payment was made. Another possible outcomeis a request made by the insurance company for the person to resubmit the claim. The reason is often to obtain additional information or to provide information that was missing in the original claim. If the claim is denied, then the entity or person filing the claim can file an appeal

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