Complex Claims: Craving Consolidation and Communication

For the first time ever, KLAS has published a report regarding complex claims services and the firms involved in that space. Recently, KLAS has been seeing a lot of questions from providers around firms that could help with specialized claims, and we have been seeing a movement from more specialized firms to broader firms that can work with multiple types of claims. The Complex Claims Services 2020 report aims to highlight the strengths and weaknesses of vendors in this space to give providers a better sense of where things are going in this rapidly changing area.

Coming Together

Historically, providers have tended to outsource many of the complex claims pieces to different firms, resulting in three or four different firms being contracted simultaneously. However, it is rare these days to find a firm that manages only one kind of complex claim; many vendors in this space tend to specialize in multiple claims, and those firms also tend to be very high performing.

Many vendors have gone through acquisitions in order to bring pieces together. Some of these acquisitions have been phenomenal, and others definitely have not. But the strong performers in this space are the firms that have been able to integrate and provide a consistent, strong experience across the board. The move toward consolidation has had a marked effect in the complex claims space, but it is not the only thing setting the top firms apart.

Communication Is Key

With more and more firms broadening their scope to cover more kinds of claims, a big differentiator among them is strong communication and account management. It is important to providers that the firms they work with know what is going on at any point in time and have visibility in the engagement. Complex claims is an interesting area; many of the firms on the complex claims side are typically very aligned with their customers, so when they are successful, the customers are successful.

These firms are paid by a percentage, and that means we tend to see most firms be more customer-centric. As shown in the report, some vendors could be stronger if they had stronger communication. Providers can get frustrated not just about missing out on strong outcomes but also about not getting basic communication throughout the claims process.

As one business office manager said, “We would probably be paying more per claim with another vendor, but the vendor is getting credit for the work my staff members are doing anyway. That situation is frustrating, and I don’t like it at all.”

Room for Improvement

Every vendor mentioned in this report has their own strengths and weaknesses, and there is always something that could be done to improve their customer satisfaction, such as increasing their touch points with their clients, increasing the number of services that they do for their clients, or making small tweaks to their processes to increase the amount of revenue they bring in for the providers. It is hard to get paid in healthcare, and it is even harder to get paid the right amount when working with payers. Anything that these firms could do to make the process a little easier and take some of the burden off of providers would serve to improve satisfaction for even the most highly satisfied customer.

What Does the Future Hold?

It is clear that the complex claims market is changing and developing, and KLAS will be sure to continue to watch and measure more options in this space. For now, be sure to look into the full Complex Claims Services 2020 report if you would like to see more information on where this market is going, who is leading it, and what to expect from your experiences with these firms.


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