Claims Management in Health Insurance and Managed Care

At the end of this training participants will be able to:

• List the steps in health insurance claims process
• understand the strategic positioning of claims management;
• identify the linkage between claims processing and customer relationship management
• identify the different categories of claims and financial management
• apply claims inventory control strategies
• describe common claims management problems and know how to avoid them
• contrast traditional and modern trends in claims management

CONTENT

• Claims: positioning, purpose, and opportunities
• Pre-authorizations and claims payment
• Claims Operations Management
• Health Insurance Claims: the process
• Types of Claims
• Organizational structure and staffing
• Claims Staffing Ratio
• Management of claims inventory
• Claims pending factors
• Types of reimbursement arrangements and claims management
• Claims Categorization
• Workflow design of claims processing
• Productivity and quality management
• Managing claims TAT
• The Functional link between the claims payment process and the authorization
• Claims coordination with other departments
• Claims business functions
• Common Claims management problems and how to avoid them
• Handling multiplicity of HCP fee schedules
• Claims processing and information technology
• Outsourcing claims processing
• Claims management and customer relationship management

TRAINING METHODOLOGY

The training methodology combines lectures, discussions, group exercises and illustrations. Participants will gain both theoretical and practical knowledge of the topics. The emphasis is on the practical application of the topics and as a result participant will go back to the workplace with both the ability and the confidence to apply the techniques learned to their duties.