In today’s highly competitive healthcare insurance environment, there’s simply no question about it. Price competition defines the industry, and the key to staying ahead of the pack lies in keeping operating costs as low as possible. Unfortunately, the way to do that is not always so easy to find. With health care costs at unprecedented high levels and labor and other operating costs constantly rising, health care payors not only must find new ways to cut costs across the board, they must also increase productivity and ensure high quality results.

More and more health care payors are discovering that one of the most effective ways to overcome their mounting challenges is outsourcing. The trend is well documented. In fact, market research has shown that 40 percent of insurance companies industry-wide have turned to outsourcing some or all of their most labor intensive functions such as call and claims processing, policy holder services, data capture and processing, and other back-office functions. Because these functions are often characterized by poorly trained or inexperienced entry-level staff and time-consuming, error-prone manual processing, the challenge is to find the right outsourcing partner.

This is where Cambridge excels. With our depth of experience in the health care insurance industry and our highly educated and skilled staff, Cambridge has consistently reduced internal process costs for our health care payor outsourcing clients by as much as 70 to 75 percent. And by shifting the burden of day-to-day management of these processes to Cambridge, our clients’ management teams can focus more attention and resources on developing and managing the core businesses.

Services include:

• Medical and Dental Claim Review - Cambridge reviews electronically submitted claims to distinguish between those that require some type of manual intervention and those that can be adjudicated automatically.
• Help Desk - Cambridge staff attempts to determine the root cause of all problems referred to the help desk, investigates claim and system issues thoroughly, and documents all findings before referral for resolution.
• Co-ordination of Benefits (COB) Data Entry -Cambridge staff completes all COB data entry to help ensure complete, accurate information prior to releasing the claim to the appropriate adjustor.
• Centralized Over-Payment System (COPS) - When claims adjudication results in over or under payment, Cambridge staff rework the claims to ensure proper payment or refund to the appropriate party.
• CRP - Cambridge ensures that the individual plan members’ claim details match the approved patient database. Any error claims are subject to a systematic workflow, based on the correction required. 
• Data Entry Audit (DEA) - Cambridge continuously audits “data entered” claims and reports the details of the audited claims to the payor on a same-day basis.
• Electronic Correspondence Handling System (ECHS) - Cambridge scans all correspondence from providers and plan members and links them to the web-based ECHS – Electronic Correspondence Handling System. ECHS stores and tracks all correspondence related to claims including claim status, requests for reconsideration, pre-authorization of a service, and {use of?} prescription drugs. Cambridge corrects or adds member information before ECHS routes the correspondence for resolution.

For more information on how your company can explore the wide range of business process outsourcing opportunities and advantages available from Cambridge, please contact us today.

Cambridge Health Care Payor Services

We get you where you need to be.

return to top