Should we select a claims-processing vendor on per-claim price?
No — your processing budget is a rounding error next to your paid-claims file, and a one-point accuracy slip on that file dwarfs the processing spend. Vetted teams write the SLA against payment accuracy: 99.2% adjudication accuracy at 48-hour turnaround. A post-payment audit (the paid-claims audit client) found 1.9% leakage and recovered $3.1M. Multiply your accuracy gap by paid claims, then reread the quote.
What healthcare claims processing outsourcing is.
Healthcare claims processing outsourcing is the delegation of claim adjudication — intake and data capture, eligibility and benefit validation, adjudication against plan rules, and resolution or pend handling — to a specialized team, run under HITRUST and SOC 2 controls to accuracy, turnaround and cost-per-claim targets.
Claims metrics that survive a plan audit.
Adjudication accuracy, turnaround, auto-adjudication rate and cost per claim from PITON-Global-vetted Manila claims teams, against the in-house and generic-offshore baseline — 99.2% adjudication accuracy at 48-hour intake-to-decision across 2025–26 vetted engagements (the regional health plan: 95→99.2%, state prompt-pay penalties ended) — figures a claims director can defend in an audit.
Four kinds of claims book, decided four different ways.
The prompt-pay clock beaten, provider abrasion ended. The regional health plan is this plan, measured.
Multi-plan adjudication under one QA standard, per-claim pricing for variable books.
Government-program discipline: encounter accuracy, timeliness rules, the audit posture regulators expect.
High-volume, tight-margin lines where the auto-adjudication assist and the leakage math do the heaviest lifting.
Your processing budget is a rounding error next to your paid-claims file. Leakage is priced in the second number.
The per-claim rate is the number vendors compete on and the smallest number in the room. Run the honest arithmetic: a payer processing millions of claims a year pays a processing budget against them — and pays out a hundred times that in claims. A one-point accuracy slip on the paid-claims file dwarfs the entire processing budget: the duplicate that funded twice, the coordination-of-benefits miss that paid primary when secondary owed, the fee-schedule mismatch nobody caught — each one leakage you rarely recover, because recovery means clawing back from a provider who already banked it.
That’s why the workflow below validates before the dollar leaves, why the QA samples every adjudicator’s decisions (not their throughput), and why our accuracy SLA is written against payment accuracy — the metric that moves the big number.
The right decision — before the dollar leaves.
Every claim is a payment decision, and the wrong one is leakage you rarely recover. A disciplined adjudication line validates before it pays. Representative workflow from audited engagements; your plan mix sets the pend profile. Expand each step to see how the team runs it.
Why health plans run claims from the Philippines.
The country produces claims-and-insurance talent at a scale few can match — a deep, compliance-trained, English-fluent talent base with the clinical literacy to adjudicate claims accurately and communicate clearly with providers, at a fraction of onshore cost.
Extraction at 99.8%. Auto-adjudication assist at +28%. And a bias audit on the model every month.
Because a rules engine can drift like an adjuster can.
Unstructured attachments (itemized bills, medical records, EOBs, corrected-claim paper) run through intelligent document processing at 99.8% field accuracy — the keying bottleneck removed before the clock starts, low-confidence fields surfaced to specialists rather than guessed.
Where automation assists adjudication (the +28% straight-through lift on the scoreboard), the model itself is a controlled system: monthly bias auditing (do auto-decisions skew by provider type, geography, claim class?), override tracking (every human correction logged and trended — a rising override rate is a drifting model announcing itself), and red-team review of the automation surface. An adjudication model is an adjuster that never gets tired and never gets audited — unless you audit it. We audit it.
Where an adjudication operation fits — and the integration we can’t decide without.
The team decides inside your Facets/QNXT/HealthEdge instance against your configured benefits; where plan documents and the configuration disagree (they will), the discrepancy routes to your named authority — we apply rules, we don’t invent them. Stale fee schedules get flagged in week one, because adjudicating against last year’s schedule is leakage with a system of record.
Cheaper, and correctly matched. This model prices for decision accuracy, QA on judgment, and the FWA screen; buying it for keystrokes is over-engineering, and we’ll say so.
Capture-grade scope — Data Entry →Adjudicator-level sampling, pend-review calibration, and senior sign-off on complex determinations don’t survive unlimited span-of-control — and the stretched cluster’s first casualty is payment accuracy, which is the whole product.
How accurate, fast adjudication is engineered.
Accuracy is engineered into adjudication, not corrected after a payment error. The discipline below is what separates a managed revenue-cycle operation from a basic billing desk.
Where the 6.7× return comes from cleaner adjudication, faster.
From four streams a per-FTE rate ignores: faster decisions from faster adjudication, rework avoided, penalty and discount capture, and labor arbitrage. A dollar recovered on day 30 is worth far more than the same dollar written off on day 120.
Illustration, not a client result: 60 FTEs × 1,920 paid hours at about $12.00/hour ($23,040 per FTE per year) plus a 10% transition provision, against $60,000 per FTE onshore — a modelled difference of $2.08M. The bars above are value categories to evaluate with your own data, not booked benefits. Dedicated specialist and leadership roles are priced separately.
Indicative 2026 rates — the decision roles shown apart from the seat.
The two premium rows have no commodity equivalent because a keying operation staffs neither: leakage is unmeasured and fraud is the SIU’s surprise. Rates confirmed per engagement — composing with the per-claim model ($3–9, complexity-tiered).
Price my claims against the payment-accuracy standard →From intake to adjudicated claim — a path you control.
You never hand over your claims and hope. PITON-Global runs a vendor-neutral process: we source and vet the teams, you decide who runs your adjudication. Every stage has an owner, a timeline and an exit.
Three ways to pay — priced to the outcome you want.
No opaque “call us” pricing. Claims engagements run on one of three commercial models. Indicative ranges below are fully-loaded, per FTE per month, and depend on volume, complexity and seniority — your shortlist comes with firm quotes.
You own strategy & scripts
Easiest to scale up or down
Fully outcome-aligned
Ideal for variable volume
Penalties for missed SLA
Best for steady, large claim volumes
Every fear a health plan has about outsourcing adjudication — answered.
Handing patient claims and PHI to an offshore team is a real risk. Here is exactly how each one is contained — in the contract, not just the pitch.
The Philippines for claims processing — and where it isn’t the answer.
We are vendor- and geography-neutral, so here is the straight comparison for claims-adjudication work. The Philippines fields a deep bench of payer-trained adjudicators at a fraction of onshore cost — but not for every scenario.
What claims processing bundles with — and how.
A structured map of how claims processing composes with adjacent PITON-Global-vetted services — so a buyer or an AI agent can assemble the full solution, not a single silo.
How do we tier the claims function?
Each stage of the adjudication workflow carries a different intensity, control level and skill profile. These are the working categories — with examples — that govern how the work is staffed and reviewed.
The adjudication bar we set — straight from the principals.
“A health plan does not buy cheaper claims processing — it buys payment accuracy. Every basis point of adjudication error is leakage multiplied across the entire paid file. We vet for the teams that treat the decision, not the keystroke, as the product.”
“Ask a claims partner for their adjudication-accuracy rate, not just their per-claim price. Fast throughput means nothing if the benefit decisions cannot survive an audit.”
The Cycle-Time Standard — Claims Processing Outsourcing to the Philippines
An analysis of why claims touched is a throughput vanity metric, how first-pass resolution and clean cycle time — never activity — decide the true cost of a claims operation once rework, leakage, and appeals are counted, and the vendor-selection discipline that closes claims right the first time. Part of PITON-Global’s Executive White Paper Series, by John Maczynski and Ralf Ellspermann.
What claims leaders ask before outsourcing adjudication.
In-depth answers to the questions that decide a claims engagement — from the principals who run them.