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AI-powered Claims Processing
Synova offers a state-of-the-art claims processing solution that significantly enhances efficiency, accuracy, and cost-effectiveness. In addition, this solution also brings automation and efficiency, adjudication accuracy and compliance, and fraud detection.
helps with
- Enhancing efficiency
- Improving adjudication accuracy
- Detecting fraud
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CMS and State Regulatory Compliance
Synova offers claims processing services ensuring adherence to CMS and state regulations. By prioritizing CMS and state regulatory compliance in the claims and adjudication process, we help you mitigate compliance risks, enhance revenue cycle integrity, and improve reimbursement accuracy.
helps with
- Mitigating compliance risks
- Enhancing revenue cycle integrity
- Improving reimbursement accuracy
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Detection of False Claims
Synova ensures that set procedures and checks are followed, ensuring that no false medical claims are approved for the financial benefit of any individual.
helps with
- Ensuring procedural compliance
- Preventing financial fraud
- Upholding ethical standards
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Claims Rejections and Denials
High rates of claims rejections and denials result in revenue loss, increased administrative costs, and delayed reimbursement, leading to delayed turnaround times and poor customer satisfaction.
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High Operational Cost
Inaccurate and incomplete claims need manual interventions and rework by payers.
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Data Integration and Interoperability
Limited interoperability between different systems, data silos, and manual data entry lead to data integration challenges and inefficiencies in claims processing. Synova implements integrated healthcare IT systems, utilizing electronic health record (EHR) integration for seamless data exchange.
Measurable Impact
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Timely Disbursal
Synova ensures that the correct claim amount is disbursed timely and accurately. The team also ensures billing and coding compliance, documentation integrity, payer contracting and reimbursement compliance, and a clean claim submission process.
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Enhanced Operational Efficiency
Streamlined claims processing workflows, automation of routine tasks, and efficient adjudication practices optimize operational efficiency, reduce manual errors, and increase productivity.
Faster Revenue Recognition
Prompt claims adjudication and accurate payment posting lead to faster revenue recognition, financial reporting accuracy, and visibility into revenue streams. This supports informed decision-making, budgeting, and financial planning.
Data Accuracy
Synova checks data accuracy using an AI-powered claims adjudication engine. This maintains the integrity of data collected to reduce the chances of claim denials.
Claims Submission
The process begins with healthcare providers submitting claims to insurance companies, government payers (such as Medicare or Medicaid), or other third-party payers. Claims can be submitted electronically using standardized formats or through paper submissions.
AI-powered Claims Processing
Upon receiving a claim, our automated claims processing system reviews the claim for accuracy, completeness, and compliance with coding guidelines, medical necessity requirements, and payer policies. This step involves initial claims scrubbing, which checks for errors, missing information, duplicate claims, and potential fraud.
AI-assisted Claims Adjudication
After claims processing, we evaluate the claim against the patient's insurance coverage, benefits, and contract terms with the payer. The claim is reviewed for eligibility, coverage determination, medical necessity, and reimbursement calculation based on fee schedules or negotiated rates.
Payment or Denial
Based on the adjudication outcome, we either approve the claim for payment or deny the claim. If approved, we issue payment to the healthcare provider.
Claims adjudication is the process by which insurance companies review and determine the validity, eligibility, and payment amount for a submitted healthcare claim.
Common reasons include:
- Incomplete or incorrect information: Errors in patient details, coding, or claim forms.
- Lack of coverage: Services not covered by the patient’s insurance plan.
- Medical necessity: Services deemed not medically necessary.
- Authorization issues: Missing or incorrect pre-authorizations.
- Timely filing: Claims submitted after the insurer’s deadline.
A clean claim is complete, accurate, and has no errors, allowing for prompt processing and payment. A dirty claim has errors or missing information, which can delay processing and require further investigation or correction.
Providers can reduce denials by:
- Ensuring accurate data entry: Double-checking patient and insurance information.
- Proper coding: Using correct and up-to-date medical codes.
- Obtaining necessary authorizations: Securing pre-approvals when required.
- Timely submission: Submitting claims within the insurer’s timeframe.
- Regular training: Keeping billing staff updated on coding guidelines and payer requirements.
An Explanation of Benefits (EOB) is a statement from the insurance company explaining what medical treatments and services were covered, the amount paid, and what the patient owes.
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Accelerated Outcomes
Value-driven Collaboration
Compliance Assurance
Bring a change to your Healthcare Operations
A partnership with Synova gives you an inherent:
Adherence towards federal, state, and organizational compliances, as well as safeguarding patient data.
Sense of ownership and commitment towards providing value.
Focus on speed, accuracy, efficiency, and optimal outcomes.
Sense of security and transparency through periodic reporting and actionable insights.
Connect with our experts for a quick analysis and possibilities.
