Medical Claim Processing: Automate Billing and optimize cash.
The financial well-being of any medical practice depends on the medical claims processing cycle. The process may be complex in terms of validating patient information as well as obtaining appropriate reimbursements. The delays, inefficiencies, or mistakes during medical claims processing may lead to denied claims, delayed payments, and there can be a wide gap in the cash flow. This blog exchange will take you through the essential procedures of medical claims processing and how the process can be improved to ensure your practice greatly enhances its revenue cycle management (RCM).
What is Medical Claims Processing and What Does It Matter?
Medical claims processing refers to the process of submitting, discussing, and paying claims placed by medical practitioners to insurance firms. It plays a critical role in ensuring that healthcare providers obtain reimbursements in a timely and correct manner. More effective processing of medical claims will ensure that there are fewer errors, faster workflow, and your practice stays afloat. Delayed payments and rejected claims may have a negative effect on your bottom line without a streamlined process.
Types of Claims
Medical Claims
The most prevalent form is medical claims, which involve instances of claims made due to medical services like a check-up visit to the doctor or a surgery, or a medical test. The health insurance companies usually work on them.
Dental Claims
These benefits claim dental procedures and treatments. They can almost always have different billing codes and can be handled under different dental insurance companies.
Pharmacy Claims
Pharmacy claims refer to prescriptions filled on behalf of the patient. These assertions typically pass via pharmaceutical benefit administrators (PBMs) or insurance firms that finance the medication expenses.
Medical Billing: Steps to follow in the Process of Submitting a Claim.
The quality of effective medical claims processing consists of the quality and timely filing of claims at every level. The main steps to go through the claim submission process are listed below:
Registration
Registering the patient is the first medical claims processing operation. This stage requires accurate information, such as personal information and insurance information.
Insurance Validation
The insurance information is then checked. This step will make sure that the insurance of the patient is in place and the policy covers the treatments. Proper validation helps prevent mistakes in the latter periods of the claim.
Patient Care
In this phase, the medical practitioner records the attention given. This covers care, diagnoses, and procedures that shall be utilized later to generate the medical codes needed when submitting the claim.
Claim Creation
The medical practitioner develops the claim, and the diagnosis and services are correctly coded by using both ICD-10 and CPT codes.
Claim Submission
After the claim is generated, the information is sent to the insurance company, whether electronically or manually. Submission techniques are also made efficient to increase the rate of approval.
Claim Verification
The insurance company even authenticates the claim. In case of any mistakes or lack of information, the open can be sent back to the medical practitioner to start the changes.
Resolution
The claim is going to be approved or rejected by the insurer. In such a case, where the claim is denied, the provider should resolve the problem and refreeze the claim.
Payment Calculation
Upon approval, the insurance company determines the amount that it is going to pay for its policy and the services provided to the patient.
Explanation of Benefits (EOB)
The insurance company sends out an EOB that has the amount paid, patient contribution, and any adjustments.
Appeal (If Necessary)
In case of the claim rejection, a provider has the opportunity to appeal against the determination, submitting supplementary documents or explaining the service offered.
Patient Billing
Lastly, any balance that the insurance failed to cover is charged to the patient, including co-pay or deductibles.
What is a medical Claim?
A medical claim is an official payment petition that healthcare professionals send to insurance providers, with specifications about the services provided and the associated prices. Claims undergo processing to establish the extent to which the insurance company will compensate the healthcare services provider. A medical claim consists of such essential information as patient information, treatment given, medical codes (ICD-10, CPT), and insurance details. It is important to get these details right so that payments are timely and accurate.
Insurance Claims Processing
Insurance claims processing encompasses the whole procedure of submission, adjudication, and payment of the claim by insurance companies. Once the healthcare provider makes a claim, the insurer will examine it to verify the precision of the claim and the coverage. It involves authenticating patients towards eligibility, medical code validation, and responsibility. It is aimed at making sure that the provider is reimbursed according to the insurance coverage of the patient. Insurance claims processing plays a significant role in a practice’s financial health, given that it directly reflects on the cash flow and operations.
CMS 1500 Claim Form
The CMS 1500 claim form is a typical document that medical companies use to file insurance claim reimbursement. It records key details regarding the patient, the medical professional, the type of services provided, and relevant codes (ICD-10, CPT, HCPCS). Non-institutional providers such as physicians, outpatient clinics, and specific multi-specialists use the form. The completion of the CMS 1500 form is an important step in assisting in processing and reimbursing it on time.
Billing and Reimbursement-electronic claim submission
Electronic claims submission enables the submission of claims to insurance companies electronically, thereby accelerating the process of submitting claims and eliminating errors. Claims are also submitted through a secure electronic route rather than sending physical paper ones, which cuts down on the time of claim processing. It is true that e-submission enhances data accuracy, reduces delays, and enables faster reimbursements. As the technology trend continues to improve, more insurance companies and healthcare providers are shifting towards an entirely electronic system of claims submissions to be more efficient.
The Benefits of Optimizing the Medical Claims Processing:
It is important to optimize the medical claims processing system to enhance the financial condition of your practice. An optimized process will result in prompt and correct Reimbursement, which is helpful to maintain a stable cash flow and reduce revenue gaps.
Cut Down on Denied Claims
Refusal of claims will result in immense stalling in payments, resulting in cash flow problems. With the help of maximizing the processing of medical claims, it is possible to minimize mistakes and enhance the precision of medical claims, which consequently leads to reduced denials.
Improve Revenue Cycle Management (RCM)
The optimized generics claim processing has a direct effect on the revenue cycle management (RCM). Lossless claims are processed promptly and correctly, and your practice can be reimbursed sooner, which accelerates financial balance and leads to less time chasing payments.
Gain an advantage over Reimbursement.
Proper and prompt filing of claims ensures that the practice can receive payment more quickly, leading to an increase in revenues. Healthcare has the opportunity to decrease administrative expenses, maximize its reimbursement rates, and achieve an improved financial result by streamlining the processing of claims.
Tips for Improving the Claims Process
Optimization of the medical claims processing system is an ongoing activity. The following are a few of the ways to streamline this process and have sooner Reimbursement:
How Can You Ensure Efficient Claims Processing with STRATUS Billing and Maximize Reimbursements for Your Practice?
STRATUS Billing offers professional medical billing services to streamline the medical claims processing. We are employing the latest AI-enabled tools and a profound understanding of the industry to minimize denials and provide claims in a proper format, at the right time. STRATUS Billing helps enhance your claims, decrease documentation errors, and improve reimbursements. The best medical billing comes with the expertise of STRATUS Billing to have your medical claims run smoothly. Schedule a Free Review Now and discover how we can streamline your revenue cycle and raise reimbursement levels in your practice.
What are the Most Typical Medical Claims Processing Coding errors?
One of the major causes of claims denials is coding errors. Some of the common problems are improper utilization of ICD-10 codes, non-inclusion of modifiers, and misapplied CPT codes. Proper training and the use of knowledgeable billing experts can greatly minimize such mistakes.
Frequently Asked Questions (FAQs)
What is the duration of the medical claims process?
Medical claims processing is subject to time, although effective processes and electronic submissions reduce commendation of time that take several weeks to a few days only.
What is the distinction between medical claims and insurance claims?
Medical claims are the claims of Reimbursement made by the healthcare provider. In contrast, insurance claims are usually the claims made by the patient to be reimbursed by their insurance plan.
What are some small practices that can make the medical claims processing simple?
Medical claims processing can be optimized through small practices by outsourcing to professional billing, such as STRATUS Billing, automated billing systems, and having proper codes and verification of claims.
Conclusion
Medical claims processing is essential in ensuring that healthcare results in payment to healthcare providers for the services they provide. An efficient claims cycle effort will result in quicker payments, decreased rejections, and a general increase in revenue cycle management. Outsourcing medical claims processing to the likes of STRATUS Billing can help enhance accuracy, lessen administrative workloads, and maximize Reimbursement.
Ready to streamline your medical claims? Contact STRATUS Billing now and find out how we can optimize your revenue cycle and help build the financial health of your practice.
