Health Care Claims Vendor Recovery
A Fortune 100 heavy equipment manufacturer with 70,000 U.S. employees had its own health provider network that contracted directly with several thousand health care providers and hospitals. The highly customized nature of this private network made it difficult for the manufacturer to find a claims adjudicator capable of processing its 200,000 monthly claims. The provider it ultimately selected was a top-tier company, but nonetheless struggled to adjudicate claims correctly.
Prior to outsourcing claims, the manufacturer had handled adjudication internally. Imperfect claims management had often resulted in overpayment of claims. Consequently, even when the new, outsourced provider did process claims correctly, the lower payments resulted in very upset employees.
Communications between the claims outsourcer and the client degraded sharply and reached a point where the two organizations were not speaking to one another. Employees of all levels were calling the CEO to complain about the claims outsourcer. Executives demanded action, but there were very few options to move to another claims adjudicator. The claims topic was generating significant internal turmoil, and the vendor/client relationship was on the verge of complete collapse.