Claims adjudicated fast, accurate, and audit-clean.
Manila-based healthcare claims-processing teams — claim intake, validation, adjudication against plan rules, and resolution, at 99.2% accuracy and a 48-hour turnaround, under HITRUST, SOC 2 and HIPAA controls.
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 (CP-089: 95%→99.2%, state prompt-pay penalties ended).
BUILT FOR THE PAYER SIDE — This page is healthcare claims — plan rules, pends, prompt-pay clocks. Deliberately.
Our depth is built for health plans, TPAs, and payer operations: Facets and QNXT fluency, benefit-plan adjudication, coordination of benefits, the prompt-pay statutes with teeth. Property, auto, travel, and P&C claims live in a different operating reality — FNOL intake, adjusters, subrogation — and that depth lives on our Insurance page, where the carrier-side story is told properly. One page, one operating model, no dilution.
Four kinds of claims book, decided four different ways.
Regional health plans
The prompt-pay clock beaten, provider abrasion ended. CP-089 is this plan, measured.
The client story (CP-089) →TPAs & self-insured administrators
Multi-plan adjudication under one QA standard, per-claim pricing for variable books.
The commercial models →Medicare Advantage & Medicaid plans
Government-program discipline: encounter accuracy, timeliness rules, the audit posture regulators expect.
RCM → Medical Coding →Dental, vision & specialty benefits
High-volume, tight-margin lines where the auto-adjudication assist and the leakage math do the heaviest lifting.
The front door, read by machine →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.
Fraud caught after payment is a recovery project. Fraud caught before adjudication is a routing rule.
Every intake batch runs the FWA screen before the rules engine sees it: pattern anomalies (the provider whose billing curve bent last month, the impossible-day schedules, the unbundling signatures), member-side flags (eligibility patterns that don’t parse, the ID used in two states on one Tuesday), and known-scheme matching against the fraud-pattern library — maintained and versioned like every rules library we run. Flagged claims don’t get denied by an algorithm; they route to the FWA desk, where trained analysts review with the full file and either clear to adjudication (most do — a flag is a question, not a verdict), pend for documentation, or escalate to your SIU with the workup attached.
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.
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.
Indicative 2026 rates — the decision roles shown apart from the seat.
How a health plan cleared a claims backlog and hit 99.2% accuracy.
A claims backlog was breaching prompt-pay deadlines, and accuracy errors were driving member complaints and re-work.
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A regional health plan faced a claims backlog that was breaching state prompt-pay timelines. Its in-house team was stretched, adjudication accuracy had slipped below 95%, payment errors drove provider abrasion and member complaints, and interest penalties were mounting.
We sourced a Manila claims team working in the plan’s adjudication platform — scrubbing intake, validating eligibility and benefits, adjudicating against plan rules and fee schedules, working edits and pends, and auditing a QA sample of every adjudicator’s decisions.
The backlog cleared in six weeks, adjudication accuracy reached 99.2%, and turnaround dropped to 48 hours — ending prompt-pay penalties — while cost per claim fell 50% and provider complaints subsided.
“The backlog disappeared, the penalties stopped, and our providers stopped calling about wrong payments. The accuracy is better than what we ran in-house, at half the cost.”
Post-payment audit only — your paid file, re-decided.
Regional health plan, live adjudication retained in-house, 24 months of paid claims in audit scope. Identity withheld under NDA.
The plan’s adjudication “ran fine” — which meant nobody had re-decided a paid claim in 6 years. Leakage was a budget-line assumption, not a measurement: duplicates, COB misses, fee-schedule mismatches, and eligibility-gap payments all presumed rare because nobody had counted. The uncomfortable question leadership finally asked: what would our own file say if we re-adjudicated it?
An audit-only engagement — live operations untouched. 24 months of paid claims re-adjudicated in sample-then-target passes: statistical sampling to size the leakage rate, then targeted sweeps on the patterns the sample surfaced (the duplicate signatures, the COB population, the schedule-mismatch window). Findings documented to recovery-grade, routed through the client’s provider-recovery workflow, and root-caused: every leakage class traced to the intake edit, configuration gap, or workflow miss that produced it.
The flagship proves live adjudication; CP-096 proves the diagnostic — and it carries the cleanest attribution in the payer set, because the baseline is the client’s own paid file and every finding is arithmetic, not opinion. The third row is the strategic sale: recoveries are satisfying, but the configuration fixes are compounding — leakage turned off at the source, every year after.
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. Volume 36 of PITON-Global’s Executive White Paper Series, by John Maczynski and Ralf Ellspermann.
Tell us your accuracy and turnaround. We’ll name the teams that can hit them.
Share your claims scope, volume and accuracy baseline. We return a vendor-neutral shortlist of compliance-led Philippine claims processing teams that have proven the numbers on this page — at no cost to you.
Run the RFP →Where the payment-integrity conversation is happening.
What claims leaders ask before outsourcing adjudication.
In-depth answers to the questions that decide a claims-processing engagement — from the principals who run them.