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What is a Claims Adjudicator?

By Dayo Akinwande
Updated Mar 02, 2024
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A claims adjudicator is a professional who determines the amount of money insurance policy holders are entitled to receive from claims. Adjudicators are also known as claims adjusters and medical bill advocates. Most claims adjudicators work as agents for property-liability insurance companies, but they also can work for other types of organizations such as banks or even for independent firms purely dedicated to claims adjudication. A claims adjudicator is required to be great, unflappable communicators since a major component of the job is interviewing and negotiating with different kinds of people – all connected by unfortunate, calamitous events.

People buy insurance to cover their property against unforeseen losses due to incidents like accidents, fire, theft, and natural disasters such as floods and earthquakes. When such losses occur, the insurance policy holder files a claim for the amount of money due under the policy. It is then the job of the claims adjudicator to assess the related events of the loss and arrive at a decision as to whether the claim is valid. In many cases, the claims adjudicator goes to the scene of the loss to ascertain that it occurred as part of the claims process. The adjudicator also speaks with witnesses and pulls up police reports of the incident for information that can be used to arrive at a final decision.

During the investigation, the claims adjudicator should display reasonable knowledge of insurance policies and practices. The adjudicator should also watch out for insurance fraud, as there is always a possibility – no matter how big or small – that the claim amount is inflated or certain statements about the loss are not true. After the investigation is concluded, the claims adjudicator prepares a report and relays the findings to the policy holder. In cases when the loss is considerably extensive, the claims adjudicator discusses the claim amount with the policy holder. The claims adjudicator not only plays the role of investigator, but also acts as a negotiator between the policy holder and the insurance company in instances of settlements to make sure that both parties accept fair arrangements.

A claim adjudicator is more specifically referred to as a medical bill advocate in the health care industry. There, the adjudicator ascertains the insurer's payment after the patient's insurance benefits are applied to the medical claim. Medical bill advocates are essential in the health care industry because of the high probability of billing errors.

The most common billing error is duplicate billing, which is charging twice for the same medical facility service or drug prescription. Other billing errors include typos, which involves the wrong dollar amount, or billing codes assigned; charges for canceled services; and upcoding, which is inflation of health care charges. It is the duty of the medical bill advocate to negotiate with the insurer to either appeal coverage denials or have charges reduced.

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