Custom medical claims management solutions

The medical claims process begins when a healthcare provider creates a claim form with patient data, diagnosis and procedure codes, services delivered, and charges incurred.

The healthcare provider then files the claim form to a clearinghouse—an intermediary between claimants and insurance payers for claims verification—or directly to the payer.

After receiving the claim, the payer initiates the adjudication process, which involves carefully evaluating the validity of the claim based on specific insurance policies.

If the claim is accepted, the payer settles the amount to be paid by the claimant based on their health insurance plan and reimburses the remaining amount to the healthcare provider.

The payer then sends the explanation of benefits (EOB) statement to the patient, outlining the services provided and payments covered by both parties. The claim is officially closed.

Our business analysts (BAs) gather, analyze, and document the healthcare provider’s goals, pain points, and business and product requirements for the final product, emphasizing clinical utilization, the target audience, and other key factors. They also estimate the resources, time frames, and expenses required for the project, establish important milestones, and identify key deliverables.

Next, our solution architects create a software architecture blueprint and define the necessary technical stack. Our designers then build a low-fidelity wireframe followed by an interactive mockup and high-fidelity prototype, all of which contribute to the final user interface/user experience (UI/UX) design. Additionally, they design user-friendly interfaces with elements like layout, navigation, color patterns, and more.

Based on the verified product prototype, we build the necessary components and functionality for the healthcare claims management software, using back-end and front-end technologies and adhering to Agile and DevOps best practices. To create a cohesive system of software components and continuously improve code quality, we conduct peer code reviews and unit testing at this stage.

Our quality assurance (QA) team then performs manual and automated testing of all functional and non-functional aspects of the final product. To ensure the software meets the established requirements, our QA engineers evaluate its integration and system capabilities, security, performance, compatibility, and more. They also identify any glitches and quickly fix them.

After comprehensive testing, the glitch-free medical claims management software is ready for deployment in the production environment and official market release. To ensure the success of the software and high adoption rates, we combine various deployment strategies like continuous deployment (CD), ramped deployment, canary deployment, rolling deployment, and more.

Once the final solution is available to the intended audience, we continuously monitor its performance, address emerging security, operational, and compliance issues, and implement the necessary improvements based on user feedback. We also provide the required updates and upgrades, ensuring the software delivers uninterrupted service 24/7 for all parties.