Pre-Adjudication of a claim is the evaluation process of all components of the claim that determines patient eligibility, benefits payable, and any patient responsibility which occurs prior to payment of the claim. It is the ideal way for our negotiators to receive a claim as this has the potential to eliminate some variables that can negatively affect the settlement outcome.

Providers often have concerns with claims that have not been adjudicated because of the variables that stand in the way of final payment.   Some of those variables being:

  • Reimbursement amount for covered services  is undetermined;
  • Patient responsibility has not been deducted out of the final reimbursement;
  • Specific claim line items or charges can be denied;
  • Claim turnaround time can be extended for additional review.

The positive impact of receiving pre-adjudicated claims outweighs the time it takes to complete the client setup for this process, furthermore, eliminating obstacles that can delay payment.  By receiving pre-adjudicated claims, our negotiators are able to obtain deeper discounts for the client and ensure a quicker payment turnaround time to the provider.

One of the common hurdles involved in the adjudication process is patient liability.  Once the patient responsibility, denied charges, and non-covered items are determined, the negotiator is left with a clear picture of the charges that are appropriate and eligible for negotiation.

By obtaining pre-adjudicated claims from the client, our negotiators are armed with accurate and complete information. This improves the overall discussion between the negotiator and provider, ensuring that their conversation is focused on obtaining a fair reimbursement for valid charges which leads to optimal savings for the client.