Health Insurance Claims Adjudication

Claims Adjudication Occurs between a Healthcare Provider Submitting a Claim to a Health Insurance Company and the Insurance Company Making a Payment Back to the Provider.

Approximately 85% of Claims are Adjudicated by Computer Software without Any Human Review. This Process is Called Auto-Adjudication. If a Human Does Review the Claim, it Costs Approximately $20 Per Claim.

Most Health Insurance Companies also Set a Dollar Threshold of $10-$15,000 Per Claim Below Which Claims are Auto-Adjudicated.

Often the Software Used in Claims Adjudication is Very Old, such as the COBOL Software Language that was Created in 1959.

Claims Adjudication Software Does Not Catch All Doctor and Hospital Billing Fraud, Waste and Abuse. For Example, ProPublica Reported at $10,000+ COVID Test That Was Paid by an Insurance Company and Quest Diagnostics Was Able to Lower its Employee Health Plan Costs by Catching Billing Errors that their Own Insurance Carrier Missed.

Please forgive the spelling errors on the whiteboard.

Sources:

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[apark]

Thank you so much for these videos. I work in a Top10 Pharma, and these videos are so much more helpful than our company trainings 😃

[lananhnguyen]

LOVE your simple yet excellent explanation. Thank you for sharing your knowledge with us!

[thelichbeats]

You summed it up in a way that my professors couldn't and now I have a better understanding of the basics of adjudication! Thanks for the video, it's an amazing supplement for learning :)

[privatestudioSS]

All heros don't wear capes, some wear a tie.
Thanks for that super simple explanation.👍🏻

[lawron]

You desire a teach of the year on YouTube. You explain things so well. 😂🎉

[edgaruriel]

Thanks for your explanation. O started to work for a medical company and there are a lot on concepts that I need to understand

[bdpatton]

you are my favorite new nerd on YouTube! thanks for the stellar content

[abirroy]

Excellent explanation. Step wise you have made it clear your each point and also it was made interesting to learn because you backed up the information with sone real time example. Thank you for the video 🎉❤

[jiezhu]

Hi, great video! Could you help to find the slide presentation by Aetna mentioned in the video?

[michaeljuergens]

Would be really interesting to see the exact auto adjudication levels for each carrier.

[AggresivelyBenign]

This is great!!! This isn’t boring at all!!

[krishvanbhavi]

Sir thank you so much of this adjudication video . I need to clarification of adjudication could you please explain that flow chart it's should be very useful to me please

[mrsbootsworkouts]

Great information! Difference payers have different process, but basicallly accurate. And yes, there’s still COBOL :). And yes, a lot of waste and abuse is going through unfortunately from Providers that cause the rates to go up for everyone.

[lisaayala]

Great video, I’m looking on a training on NASCO platform for healthcare claims, any suggestions? Thanks

[michaelli]

really appreciated. can you shard the link the aetna slide on claim adjudication?

[menoldomare]

This was great. Mind uploading a video on authorizations. Thank you

[DeeDee-lrnb]

It may have went through, but trust they will catch it and retract it.

[jimmie-satx]

This video was great. I have a unique scenario about discriminatory exclusions for a certain procedure and I have an uphill battle on this one. I do like a challenge though (My law professors see that and love it) so I am taking on Cigna at the moment. Should be interesting. .

[WRTH]

Is this the same situation for self funded companies that use TPA's services to adjudicate in the USA?

[paulramirez]

Hmm interesting. Thanks for that video. I wonder with the rise artificial intelligence which gets smarter the bigger the dataset (similar to how Facebook face recognition, once a user gets tagged enough, Facebooks algorithm automatically understands who they are in new photos) that this process can also see a huge benefit in that regard, especially with more complex claims.