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Sutherland Healthcare Group Created with Sketch.

Claims Processing

Claims Data Entry

Health plans deal with large volumes of claims on a daily basis. Often times claims data needs to be scrubbed and entered into a format or system in order to quickly validate the information, adjudicate the claim against a schedule of benefits, and pay the correct provider.

At Sutherland, we are experts at the delicate task of indexing and processing claims data. Our mailroom and scanning facilities help to not only improve current data entry processes but also help health plans digitize their current data entry processes.

Pended Claims Resolution

The process of investigating and resolving a pended claim can be a complex and resource-intensive task. While there a pend reasons that are common to all health plan, the root cause of the pend can be unique to the health plan’s environment and, often times health plans do not have the resources to resolve and proactively prevent future pended claims issues through a root cause analysis.

At Sutherland, we process the backlog of pended claims health plans face. Most importantly, we then work closely with our clients to deploy proactive fixes so claims can avoid being pended in the first place and then work on ways to improve auto-adjudication rates. This helps health plans improve their turnaround times and decrease their claims operations costs.

Claims Repricing

The emphasis on managed care has created the need for health plans to reprice many standard codes to correspond with their focus on decreasing costs and improving quality of care. Unfortunately, because the reimbursement methodologies are so varied and can be incredibly complex, many health plans still struggle with the process of repricing their in-network and out-of-network provider contracts. In today’s rapidly value-based health era, it’s imperative for health plans to leverage proper claims repricing processes to ensure their claims are correctly adjusted and done so in a timely manner.

Sutherland helps health plans put in place processes that properly manage and reprice their claims. Our scalable and integrated solution helps health plans save costs and time by quickly obtaining health provider sign-off of negotiated discounts and minimizing turnaround and appeal times.

Claims Adjudication

The adjudication of claims is one of the most important processes that a health plan performs. Unfortunately, many health plans are still bogged down by inefficient claims processes and outdated technology that makes the process slower and costlier than it should be.

Sutherland’s dedicated team of claims analysts and adjudicators support health plans throughout the entire claims adjudication process. We work with our clients to transform the process from receiving the medical claim, entering data, verifying key pieces of information, and then to processing the claim for payment. We speed up turnaround times through higher auto-adjudication rates and decrease overall claims operations costs.

The impact (value, savings)
  • Improve the accuracy of claims adjudication
  • Improve turnaround time so that prompt pay penalties are avoided.
  • Improve auto-adjudication rates and lower cost of administration through analysis of pended claims
  • Global delivery model to provide 24/7 support
  • Lower administrative costs to better meet medical loss ratio and other regulatory requirements
Our experience
  • Two of the top five US health plans are claims processing clients
  • >300 dedicated claims adjudication specialists
  • >12 years’ experience
Who we help
  • Large, national health plans
  • Regional and BCBS health plans
  • Government health insurance programs
Our differentiators

Blend of consultants and digital experts

Sutherland is able to provide a truly transformational claims processing offering through our blend of claims processing consultants and digital team. By combining these specialists, we are able to re-think and re-engineer legacy claims processing workflows and systems.

Opening/Introductory

Processing claims is an incredibly complex and time-consuming task for health plans. If claims are not filed correctly by the health provider or if a health plan experiences any issues with their internal claims processing systems, then the member experience and the health plan’s bottom line are negatively impacted.

Sutherland understand the importance of having a well-run claims processing department and how it helps create a positive member experience and improve a health plan’s bottom-line. We work to automate and simplify the task of processing claims so health plans can lower their turnaround time, improve their adjudication rates, and increase member satisfaction.