Register now or log in to join your professional community.
Everything depends on the edits and complexity of policy. The ultimate goal of the adjudication is to be automated due to the number of claims.
Fraud and Abuse can be a department in the form of Analytics that can be a supporting part of automated claim adjudication. Major insurance companies trying to focus on insurance plans rather than thinking about the claims adjudication.
There is a simple and perfect example of Outpatient Code Edits from CMS and many more are maintained internally. Clearinghouse softwares are playing a vital role in automation.
