The Value Of Accurate Medical Claim Processing In Healthcare​

Medical claims processing is the process of filing and confirming bills for healthcare services supplied to patients. It includes several phases: eligibility verification, authorization, coding, billing, and payment. It impacts healthcare provider payments, the cost and quality of healthcare for patients, and the system’s efficiency and accuracy.

Medical claims processing is not always simple or error-free. According to American Medical Association research, around 9% of physician claims were refused, with an additional 2% partially declined. Denials might be based on missing or incorrect data, duplicate or expired claims, a lack of medical necessity, or non-covered treatments. These denials can cause delays, arguments, and losses for providers and patients.

Accurate medical claim processing is an essential component of the healthcare system. It must be constantly monitored, updated, and improved to suit the changing demands and expectations of the healthcare business and society. Investing in technology, training, and teamwork allows providers and payers to accomplish accurate medical claims processing and enjoy the rewards.

How Medical Claims Processing Work

When a patient visits a healthcare practitioner, the practitioner creates a medical record including the patient’s information, diagnosis, and treatment plan. The provider then assigns codes to the services provided using defined systems like ICD-10 and CPT. These codes indicate the medical necessity and complexity of the services to the Payer (often an insurance company or a government program).

The provider submits a claim to the Payer, either online or by mail, along with the applicable codes and costs. The Payer gets the claim and evaluates it for correctness, validity, and coverage. This process is known as adjudication. The Payer may accept, deny, or alter the claim according to the terms of the patient’s insurance and the provider’s contract and may also seek more information or documents from the physician or patient to verify the claim.

The Payer sends the provider and the patient an explanation of benefits (EOB) or remittance advice (RA) outlining the outcome of the claim. The EOB or RA shows the amount billed, the amount permitted, the amount paid, and the amount due by the patient. If the healthcare provider or patient disagrees with the Payer’s decision, they can study the EOB or RA and appeal.

The Payer sends the provider the agreed-upon amount via check, direct deposit, or electronic money transfer. The provider may also charge the patient for any outstanding debt, such as deductibles, coinsurance, or copayments, and the patient may pay the provider the amount owed via cash, cheque, credit card, or another method.

Common Challenges and Solutions for Medical Claims Processing

Medical claims processing may be complicated because it involves numerous aspects and variables, such as differing rules, codes, and rates across different payers, which might change often and require continual updates. Errors or inconsistencies in coding, paperwork, or claim submission can result in claim rejection, denial, or delays. 

Legal, ethical, and regulatory considerations, such as privacy, permission, licensing, and compliance, might impact the claims’ validity and security. The billing and payment process’s quickness, accuracy, and transparency can impact patient satisfaction and loyalty.

To solve these issues and improve medical claims processing, consider using a medical claims clearinghouse as an electronic mediator between healthcare providers and payers. Clearinghouses can assist you in scrubbing, standardizing, and screening your medical claims before submitting them to payers, decreasing mistakes and denials. 

Use medical billing software to automate and simplify the medical billing process. Medical billing software can help you with coding, submitting, tracking, and managing medical claims and generating reports and analytics. Outsource your medical billing services, which may assist you with all medical billing and revenue cycle management elements. 

Outsourcing your medical billing services to a reputable business, such as BLS Medical Billing, may help you save time and money, increase cash flow and profitability, and concentrate on your core skill of delivering excellent care to patients.

Benefits Of Effective Medical Claim Processing

Effective medical claims processing is critical for the healthcare care business and society. Here are some benefits of Effective medical claim processing:

• It minimizes administrative expenses and mistakes for providers and payers, saving time and money. 
• It helps providers manage their cash flow and revenue cycles, guaranteeing timely and proper payment. Providers can improve their financial performance and sustainability by minimizing rejections and speeding up payments.
• It improves patient satisfaction and loyalty by reducing billing issues and confusion. By providing clear and accurate billing information, healthcare providers can increase patient confidence and retention.
• Effective claims processing helps to enhance quality and monitor performance by giving data and comments on medical services and results. Providers and payers may track and assess healthcare delivery and payment quality, cost, and effectiveness by utilizing consistent and correct codes. It can assist in identifying best practices, gaps, and possibilities for improvement.
• Precise claim processing ensures compliance and responsibility by following health care delivery and payment norms and standards. Providers and payers can avoid audits, penalties, and lawsuits by following the regulations and standards of numerous institutions, such as the Centers for Medicare and Medicaid Services, the Office of Inspector General, and the Health Insurance Portability and Accountability Act.

Final Thoughts

Medical claims processing is submitting and confirming invoices for healthcare services delivered to patients. It is a complicated and dynamic process involving several parties, norms, and technology. Accurate medical claims processing is critical for the healthcare sector and society because it influences provider compensation, patient cost and quality of care, and the healthcare system’s efficiency and accuracy. Investing in technology, training, and teamwork allows providers and payers to complete accurate medical claims processing and enjoy the rewards.