Health Insurance Business Process Outsourcing

Consolidation, escalating service levels, and diminishing margins are spurring payers to outsource data entry, claim processing and related functions. Eldorado differentiates itself by moving beyond sheer labor cost-savings of 30+% to envelop long-term operational improvements.

Ranked among the top 5 service providers by The Black Book of Outsourcing, Eldorado provides health payers with a blended on-shore off-shore administrative model to optimize our client partnerships. Our BPO team is locally based, providing the executive governance essential to facilitating ongoing client collaboration.

Eldorado is also committed to risk mitigation. By hiring only those professionals with experience in U.S. and international health insurance administration procedures, we can ensure quality in all facets of our production. Our hiring, training and testing practices are explicitly documented to ensure strict compliance to each client’s business rules as well as to mandated regulations such as HIPAA.

BPO competencies include:

• Flexible deployment on the payer’s platform(s) or ours
• Dedicated, client-specific health insurance staff
• Guaranteed Service Level Agreement performance with penalties
• Continuous process improvement utilizing Six Sigma methodologies
• BS7799-2 security

The Eldorado health insurance team consists of professionals that have more than 100 years of combined, hands-on experience in operations, product development, data conversion, consulting, customer support, training, system configuration and quality assurance.

Today Eldorado seamlessly manages 57 million annual transactions for leading insurers, financial institutions and others. We are driven toward architecting value by producing quality output that improves the profitability as well as competitiveness of our clients.

HEALTHpac BPO

Eldorado’s healthcare platform is a comprehensive health benefits management system. The HEALTHpac platform has been subject to over 20 years of continuous development in response to more than 125 clients administering medical, dental, HMO, PPO, pharmacy, flex and vision plans.

Designed as a fully integrated software product, HEALTHpac enables clients to achieve in excess of 70% auto-adjudication, thereby resulting in increased efficiency. Real-time workflow, along with on-line servicing and reporting, crystallize both transaction and data management.

Beginning with plan building

Experienced HEALTHpac professionals can accelerate and optimize your plan building processes to bring new groups on rapidly. This team can also assist with plan design consulting, monitoring your exception traffic in an effort to increase automation.

Data entry

Enrollment and claims data entry can make a dramatic difference in meeting your Service Level Agreements. Our rigorous quality assurance standards include code and field validation.

Claims processing

Your specific business rules can readily be adapted using HEALTHpac and its user-defined workflow parameters. Claims may be routed according to high dollar, specific diagnosis and other review criteria.

Fully Integrated Claims Edit System Stops Costly Overpayments Medical overpayments attributed to upcoding of claims can automatically be detected and corrected. The system identifies surgical, laboratory, radiology and medical procedures that are inappropriately coded, and, at the user’s option, by group, automatically corrects the errors.

Support for Virtually any Fee Schedule Ensures Appropriate Payments

The platform supports virtually all pricing databases such as medical, dental, anesthesia as well as specific user-created fee schedules.

Electronic Data Interchange Speeds Processing (Incoming-Outgoing)

HIPAA-compliant claims and related transactions can be directly received or expedited electronically through our X-12 Manager.

Platform Independent BPO

Many payers are operating on a variety of systems and simply not prepared to manage the risk of a platform migration. Eldorado has extensive experience in providing back office processing on a variety of legacy applications.

As part of our due diligence and transition strategy, we document each aspect of our client’s business system and rules to validate training and procedures. This in-depth assessment enables us to replicate your existing processes, thereby ensuring a predictable execution as an extension of your enterprise.

Our health insurance team has experience with many major payer platforms, including those that may be homegrown. Most importantly, our domain experts have a thorough understanding of insurance operation best practices including:

• Benefit plan design, construction, and optimization
• Workflow design and integration
• Group and eligibility coordination
• Provider/Network pricing design, construction, and optimization
• Billing and administration
• EDI configuration and standards
• Utilization management
• Inbound-outbound Mailroom functions
• Product and process integration

Our BPO offering commences with client collaboration to clarify cost-savings, along a transformation plan to reach escalated production targets. Eldorado initially guarantees to match or exceed your existing service levels by your go-live date. Following this transition, we then target and guarantee increased performance production utilizing our Six Sigma methodologies.