For Payers
Claims administration
Do more with less across your entire organization with insightful, end-to-end claims management
Claims outsourcing is rife with metrics — accuracy, turnaround time, etc. Claims metrics alone, however, miss the mark in yielding meaningful benefits to your organization.
The truly meaningful benefits are hard to measure in siloed claims departments — such as brand perception improvements, new member referrals, satisfaction levels, etc.
Only a true partner with a view of the end-to-end claims process can deliver value-added benefits to claims and your organization as a whole.
HGS Healthcare, a leader in transformative healthcare solutions, can manage all or singular aspects of claims, help you avoid the downstream impacts of mishandled claims, and truly differentiate your organization.
Improve intake processes
Increase speed and efficiency
Reduce inaccuracies and rework
Enhance provider and member satisfaction
Reduce fraud, waste, and leakage
Optimize claim payment and support
Reduce grievances, complaints, and calls
Protect the brand and improve perception
Improve scalability and business continuity
Increase transparency and trust
While most claims adjudication processes have been automated, what falls out of auto-adjudication are the highly complex claims. Resolving issues with these claims requires an understanding of plans, members, and providers; adjudication platform(s); as well as the contractual, medical policy, and coding outliers. With a deep understanding of both payer and provider operations, we partner with you to continuously improve and innovate.
Exceed service level targets with optimized software — Facets, QNXT, HealthRules Payor, InsPro, Amisys, PowerHMS, Mainframes, and more.
With an in-house HGS Healthcare Technology team and an understanding of upstream and downstream impacts of system changes, our team can help you overcome IT obstacles with:
50 states we work with regional plans and the largest national plans
72 Mclaims handled annually
$65 Bin payouts handled annually
20different claims platforms
+99.9metric efficiency for all health plans
3.5 yearsaverage tenure for claims agents
$100 Msavings for clients every year, resulting from clinical and code reviews
6100 FTEsacross 3 different geographies
With HGS Healthcare, up to 80% of claims can be processed automatically. Our claims team works to continuously improve automatic processes, while also preparing to handle the unusual claims – the exceptions.
Our claims specialists train for an average of six months. They are fully equipped to handle rework and the 20% of claims that require a complete review and application of benefits, pre-authorization decisions, and contractual carve-outs.
We take a “can do” approach to claims, as we aim to provide value, not just metrics. We proactively flag pre- and post-pay deficiencies so they may be investigated to avoid further issues.
Our Claims Center of Excellence (CCOE) harvests the very best ideas to promote collaboration and continuous improvement.
The CCOE is involved in: