A claims adjudicator is a professional who determines how much money policyholders are entitled to from claims. Claims adjusters and medical bill advocates are other terms for adjudicators. The majority of claims adjudicators work as agents for property-liability insurance companies, but they can also work for other types of businesses, such as banks or even solely for claims adjudication firms. Because a large part of the job entails interviewing and negotiating with various types of people – all of whom are linked by unfortunate, calamitous events – a claims adjudicator must be excellent, unflappable communicators.
People purchase insurance to protect their assets from unforeseen losses caused by accidents, fire, theft, and natural disasters such as floods and earthquakes. When such losses occur, the policyholder files a claim for the money owed under the policy. The claims adjudicator’s job is then to evaluate the loss’s related events and make a decision on whether or not the claim is valid. In many cases, the claims adjudicator visits the site of the loss to confirm that it happened during the claims process. The adjudicator also interviews witnesses and searches police reports for information that can be used to reach a final decision.
The claims adjudicator should demonstrate reasonable knowledge of insurance policies and practices during the investigation. The adjudicator should also keep an eye out for insurance fraud, as there is always the possibility that the claim amount is inflated or that certain statements about the loss are false, regardless of how big or small the loss is. After the investigation is completed, the claims adjudicator writes a report and informs the policyholder of the findings. When the loss is significant, the claims adjudicator meets with the policyholder to discuss the claim amount. In cases of settlements, the claims adjudicator not only acts as an investigator, but also as a negotiator between the policyholder and the insurance company to ensure that both parties accept fair arrangements.
In the health-care industry, a claim adjudicator is more specifically known as a medical bill advocate. After the patient’s insurance benefits are applied to the medical claim, the adjudicator determines the insurer’s payment. Because of the high likelihood of billing errors, medical bill advocates are essential in the health-care industry.
Duplicate billing is the most common billing error, which involves charging twice for the same medical facility service or drug prescription. Other billing errors include typos (incorrect dollar amounts or billing codes assigned); charges for canceled services; and upcoding (increased health care charges). The medical bill advocate’s job is to negotiate with the insurer to either appeal coverage denials or reduce charges.