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Healthcare claims processing covers the full lifecycle of a medical claim — from preparation and scrubbing through electronic submission, payer adjudication support, rejection resolution, and denial management. It is the critical link between care delivered and revenue collected, and even small error rates compound into major financial losses when multiplied across thousands of monthly claims.
The average healthcare organization sees 5–15% of claims denied on first submission, and industry data shows that up to 65% of denied claims are never resubmitted — representing permanently lost revenue. Each reworked claim costs $25–$118 to correct and resubmit. For payers, inaccurate claims intake and slow adjudication drive up administrative costs and member dissatisfaction. Claims processing is where financial performance is won or lost.
SkyCom's claims processing BPO delivers accurate, high-volume claims handling for both healthcare providers and payers — combining trained claims specialists, structured quality control, and payer-specific expertise to maximize first-pass acceptance and recover revenue that would otherwise be written off.
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The full claims lifecycle — claims preparation and scrubbing, electronic submission (EDI 837), clearinghouse management, adjudication support for payers, coordination of benefits, pended claims resolution, denial management, corrected claim resubmission, and appeals. We serve both providers submitting claims and payers adjudicating them.
Yes. For providers, we handle claim preparation, submission, and denial management to maximize reimbursement. For payers and TPAs, we handle claims intake, adjudication support, benefit determination, and pended claims resolution to accelerate processing while maintaining accuracy and compliance.
Pre-submission claim scrubbing validates every claim against coding accuracy, demographic completeness, and payer-specific edit rules before it’s sent. Combined with structured QA and payer-specific formatting, this drives first-pass acceptance above 95% versus the 85–90% industry average — meaning faster payment and less rework.
Every denial is categorized by root cause, corrected, and resubmitted or appealed through payer-specific workflows. We analyze denial trends to eliminate recurring errors at the source, recovering the up to 65% of denied claims that most organizations never resubmit and reducing overall denial rates 30–40%.
Major clearinghouses (Availity, Change Healthcare, Waystar, Trizetto) and EHR/PM systems including Epic, Cerner, MEDITECH, athenahealth, eClinicalWorks, NextGen, and proprietary platforms. We work directly in your submission environment with no separate system required.
HIPAA, PCI DSS, SOC 2 Type II, and ISO 27001 certified. Claims data containing PHI and financial information is encrypted with AES-256, access is role-based with MFA, BAAs are executed with all clients, and we undergo regular third-party audits. Access is terminated within one hour of staff separation.
4–8 weeks including baseline analysis, clearinghouse/EHR integration, specialist training, HIPAA certification, and QA setup — with parallel processing to ensure no cash flow disruption during transition. Denial backlog projects can begin immediately alongside go-live.
First-pass acceptance above 95%, denial rates 30–40% below baseline, days in AR reduced by 15–25 days, recovery of previously written-off denials, and 50–70% lower claims processing costs versus in-house staffing — with measurable improvement typically within the first 90 days.
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