By Siva Namasivayam, Chief Revenue Officer and Senior Vice President, MphasiS BPO,
and
Zane Bell, Vice Chairman, Eldorado Computing, Inc.

Managed care organizations and healthcare payors realize how outsourcing business processes to experts allows them to focus on their core business without worrying about back-office functions. Business Process Outsourcing (BPO) is the leveraging of technology or service providers to provide and manage an organization’s critical and/or non-critical business enterprise processes and applications, such as payroll, accounts payable, billing and claims adjudication.

by David Jackson
Bloodhound Technologies

Claims editing involves checking claims for upcoding, bundling and unbundling of codes and duplicate entries. Claims editing typically saves payors between 3-8%. While many off the shelf claims transaction systems have some native editing and duplicate checking abilities, these systems are designed to adjudicate claims. As such, even the most robust transaction systems need some augmentation to their native editing sets and duplicate logic. 

by Arjomand Rahimzadeh, President EDIWatch

Insurance fraud is a distressing reality, and it’s growing at an increasing and alarming rate. In this millennium fraud, waste, and abuse losses in the healthcare industry have been conservatively estimated at $100 billion dollars per year, and at 5-10% of total claims paid out. Therefore, if your company pays $50 million in claims per year, your company could be paying out up to $5 million for suspect Fraud, Waste, and Abuse (FWA) claims.

The challenges for healthcare organizations are intense. Successfully tackling issues like rising healthcare costs and recruiting skilled staff requires innovation, focus and the tools to make good decisions quickly and execute on them well. However, HR in healthcare often faces the same obstacles as HR in other industries – a lack of effective tools to address HR administration and provide a platform for innovation, combined with a lack of reliable information access to help drive the type of decisions that can make a difference.

HR at one company, MemorialCare Medical Centers in California, has found the means to overcome that via co-sourcing.