Medical claim processing essentially terrifies many businesses and healthcare providers. From submitting a claim to gathering various documents and completing the payment finalization every aspect of the claims process can be quite challenging to grasp. Mastering the intricacies of the claim’s procedure is essential for executing the process both accurately and swiftly.
Understanding the way to handle claims efficiently saves considerable time and resources. This blog aims to provide an exploration of what medical claim processing entails and how to do it effectively. It will cover the types of claims and the steps involved in the process and offer tips on streamlining the procedure for maximum efficiency. Stay connected with us till the end!
What Is Medical Claim Processing?
Medical claim processing involves keeping records of claims and payments. While it plays a role in the insurance process, not all insurers provide claims processing services. In most cases, it’s up to the insured party to handle the claims process. It includes monitoring the progress of their claims, obtaining the necessary documents, and overseeing the payment procedure.
The first, very important step in the whole process of healthcare claims submission involves checking whether the patient is properly registered and has enough insurance. If the insurance company manages the claims process, they will inform the individual or business about the specifics of their claims. Although the details of how claims are processed may differ between insurers, there are fundamental elements that are consistent across all claims.
Claim Submission Process in Medical Billing
In the process of medical billing, claim submission involves the transmittal of prepared and coded medical claims by us for reimbursement to insurance companies. It starts right after the provision of healthcare services, and we must ensure that all information about the patient, the diagnosis code, and treatment details are correctly documented. Accurate coding and thorough documentation are vital during healthcare claims submission to avoid claim denials and ensure that the services rendered are correctly represented.
These are then formatted, according to the particular needs of the insurance provider, through an electronic submission or on paper claims. We also recheck data for accuracy to avoid any delays or rejections. Proper claim submission is critical for effective revenue cycle management in any healthcare practice.
How Does a Medical Claim Work?
A health insurance claim is a request for payments made by a policyholder to the insurance company. A claim can be filed when the policyholder needs money for treatment of a minor or significant sickness covered in the health plan, an accident, an injury, or any other medical condition. Medical billing involves several claims processing steps, such as:
1-Patient Registration
When a patient phones to schedule an appointment with a healthcare professional, they are essentially preregistering for their doctor’s visit. If the patient has previously seen the physician, their information is already on file, and the patient simply needs to describe the purpose of their appointment. If the patient is new, they must supply the provider with personal and insurance information to establish their eligibility for services.
2- Insurance Verification
It can be very simple to verify insurance. You have been given the insurance information of the patient, you call the patient’s insurance carrier to which the patient belongs and verify their information. Most frequently, a telephone number is printed on a patient’s insurance card that you can call to confirm their information. After getting to a representative at the insurance carrier, you may ask if the patient’s coverage is active and what their benefits are. You need to ask them about the deductibles, co-pays, coverage, and benefits so you can tell how much you will have to collect from the patient.
3-Claim Preparation
The very initial step is verifying patient information and insurance details for accuracy. Next, you’ll gather all necessary medical records and documentation. The heart of healthcare claims submission lies in preparing a complete and accurate claim that adheres to the insurance company’s guidelines for a successful submission. You calculate the charges and generate the claim after coding.
4- Claim Transmission
Clearinghouses serve an important role in facilitating the electronic exchange of data among healthcare providers, payers, and other accountable resources. Clearinghouses serve as middlemen, translating data from proprietary forms utilized by various systems into standardized formats that are understood by all parties involved. HIPAA does not force psychiatrists to perform all transactions electronically. Only the standard transactions specified in HIPAA rules must be conducted electronically. Claims are one such typical transaction.
5- Patient Statement
Once the biller has received the payer’s report, it is time to prepare the statement for the patient. The statement is a bill for the procedure or procedures that the patient got from the provider. If the payer has agreed to pay the provider some of the cash listed on the claim for the services, then the remaining cash is sent to the patient. In some cases, the biller also provides an Explanation of Benefits along with the statement. An EOB describes the benefits and the cover under which a patient is entitled in the particular plan.
6- Follow-Ups
The final step of invoicing is making sure the invoices are actually paid. Therefore, billing staff send out timely and accurate medical bills to the patient and follow up on the payment when a patient is lagging in paying their medical bill. Payment information is then filed in the patient’s file. It usually means that if the patient is slow to make a payment, there is a partial payment, or no payment is made, the biller will try to see that the provider is fairly paid for his services.
Stages of Processing in Medical Billing
i-Initial Review
Claims adjudication process: First initial review: After the insurance company receives a claim, it first checks the claim to identify some of the basic information. The insurer only looks at the claim for the patient’s name, diagnostic code, site of treatment, and service code. If any one of the above pieces of information is missing or wrong, the insurance rejects the claim. If they are found in good order, then the claim enters the next level of the adjudication process.
ii-Automatic Review
Claims adjudication process: First initial review: After the insurance company receives a claim, it first checks the claim to identify some of the basic information. The insurer only looks at the claim for the patient’s name, diagnostic code, site of treatment, and service code. If any one of the above pieces of information is missing or wrong, the insurance rejects the claim. If they are found in good order, then the claim enters the next level of the adjudication process.
iii-Manual Review
About 80% of claims are simple enough to be decided wholly by automated review or with a fast scan by a human medical reviewer. The remaining 20% are highly difficult and expensive claims. These are turned over to a medical claim examiner who does a thorough manual review of the claim. The reviewers can also be doctors or nurses, which may vary based on the situation and the insurance involved.
iv-Decision
Once a claim has been assessed, the insurance company will make a payout decision. The insurer agrees to pay a claim at an agreed-on value in the ideal case. Sometimes, the insurance pays at a lower rate. It happens when the payer believes that the amount charged is too much for the diagnosis of the patient. Hence, the company allows a lower-level, less costly procedure code for payment instead of completely denying the claim.
Types of Claims processing
Health insurance companies categorize claims into several sorts. It is determined by factors such as the services provided, the type of insurance coverage obtained, and the billing process.
1. Medical Claims
A bill a physician submits for medical care to a health insurer. These may be obtained from a patient’s attending physician’s office, urgent care facility, hospital, emergency department, or healthcare provider.
2. Dental Claims
A claim is a formal request for payment by a dental treatment provider to an insurer. A dental claim summarizes all services and procedures that your dentist and their team provided during the patient’s visit.
3. Pharmacy Claims
The pharmacy will, in turn, bill the health insurance company for the filled prescriptions by the patient. It may be applied to regular prescriptions and medicines needed for other treatments, such as those in a hospital. In such cases, you may have both medical and pharmaceutical claims for the same treatment session.
Medical Claim Processing Steps in Healthcare
The process of a claim starts well before you book an appointment. It’s essential to check your health insurance to see what services or procedures are covered and where to find in-network care since not everything is always covered by insurance. Once you’ve figured out what’s included and located a doctor, you reach out to schedule an appointment. After receiving your care, the claim is processed relatively quickly. Here are the steps your claim goes through after an appointment until you receive the final bill.
- Insurance receives a bill for service charges, not counting co-pays paid at check-in.
- A qualified claims processor reviews claims for accuracy and compares them to insurance plans to ensure coverage.
- If benefits cover services, insurance companies will pay claims depending on coverage. They may pay the entire claim in full, depending on your plan; otherwise, you, the patient, would be invoiced for the remaining balance.
- Validated amounts will be allocated to deductible and out-of-pocket costs based on your insurance plan. They will be updated promptly.
- An explanation of benefits is delivered, including a summary of services rendered, insurance coverage, provider payments, and outstanding bills.
- Before settling the claim, compare the EOB and final bill to ensure accuracy and correct billing. Sometimes, balances do not match, which could be due to a mismatched process code or another clerical error. Claims can be revised and corrected without consequence to you.
How Does Health Care Claims Processing Work?
Medical claim processing in health care entails the submission, review, and approval of medical claims by an insurance company. First, it includes data on the healthcare services provided-diagnostic codes, treatment information, and charges related to each billing and claims processing.
Then, the insurance company reviews the claim, verifying patient eligibility, service necessity, and policy coverage. If approved, the insurer reimburses the provider according to the terms of the policy. If denied, the claim may be returned for correction or appeal.
Tips For Improving the Claims Process
1.Automate the Claims Process
Smoothening the process is the key to enhancement in efficiency. Advanced management software can be employed in smoothing tasks related to reporting, managing, and follow-ups of claims. Automation of processes reduces the level of input required, cuts down on errors, and raises the pace of the entire workflow. Moreover, technology can allow real-time updates so that we monitor the claims with efficiency and thus take prompt action where needed.
2. Focus on Accurate Documentation
Proper record-keeping and completion are important for the efficiency of medical claim processing. For this reason, correct data entry of all information about the patient, codes, and other relevant information at the commencement of services is important. One of the common reasons for denial of claims is incorrect or incomplete data entry. Training employees regarding billing codes, compliance requirements, and the best means of documentation can help keep standards maintained.
3.Healthcare Claims Management
Claims management refers to the overall process of managing medical claims submitted for payment. It incorporates a structured approach in organizing, filling, and processing the claims involved with the rendered medical services, starting from reporting to investigation, evaluation, and settlement. Where there is an effective claim managing strategy, you are bound to achieve smooth processes, better cost control, and consequent improvement in customer satisfaction.
4.Streamline Communication Resources
Effective communication is critical to a successful claim procedure. We can improve communication by consolidating it into a single platform that connects billing teams, healthcare providers, and insurance companies. This strategy allows for faster settlement of any difficulties that arise during the claim’s procedure, hence reducing delays. Furthermore, delivering transparent status updates to all stakeholders keeps everyone informed and minimizes the possibility of misunderstandings or miscommunications.
5.Proactively Manage Denials
Claim denials are inevitable, but it’s our response that can make all the difference. Picking through the details of the denied claims facilitates the spotting of trends and the identification of root causes. This approach encompasses more than just determining the root causes of claim denials; it deals with instituting a method that can help in responding to those issues as soon as possible. It could mean the development of claims reporting policies or putting up support in the fight against denials.
6.Measure and Optimize Performance
It is crucial to track key performance indicators like as approval rates, processing timeframes, and claim denial rates. These indicators provide critical feedback on the process’s success and can assist in identifying areas for improvement.
End Note
Accurate and timely medical claims processing is vital in running a successful insurance company. If you work within the claims department, then it is your responsibility to ensure that all claims are properly processed and paid out on time. All claims should have relevance to one another, even though some claims may be more relevant than others. It is equally vital to ensure that all claims are received correctly and reimbursed as promptly as possible. Effective healthcare claims submission doesn’t end with submission; it involves diligent follow-up to resolve any issues, such as denials, and ensure timely reimbursement .You may reach out to MAVA Care for more information, including claims processing, medical coding, and follow-ups.
