When healthcare providers deliver services to patients, they are reimbursed by submitting invoices to the insurance companies that cover the medical services. Essential factors, including patient demographics and plan coverage specifics, are included in these claims. The claims are sent to the Payers.
What is Medical Claim?
An official medical claim is a payment request made by your healthcare provider to your health insurance provider. It ensures that the doctor will receive payment, your insurance will pay the amount, and you will be responsible for paying any outstanding balance. A claim is started as soon as a patient shows up for their appointment. Until the patient receives and pays the final bill, it follows a health service’s whole route. Medical claims billing service centers strictly adhere to HIPAA regulations to protect the security and safety of such sensitive data.
Here is an explanation of the 7 steps of the medical claims billing service:
Medical Claims Billing Service Process
Medical Claims Billing Service follows procedures to guarantee correctness and approval. Even before you schedule an appointment, a claim’s journey acts. Examining your health insurance is crucial to know what is covered and where to go for in-network care because insurance may not always cover all services or procedures. After determining what is covered and locating a doctor, you schedule an appointment. The claim is processed shortly after you receive your services.
Patient registration before the appointment you should ask patients for their basic personal information and insurance information before every consultation. This process can be streamlined with medical practice management software, enabling patients to submit their information before visiting your office.
Verification of benefits (VOB)
You should confirm whether their plan covers your services now that you have access to your patient’s insurance information. Enter the insurance provider portal and perform all required checks to do this. An alternative is to give the provider a call; the representative you speak with will be able to tell you whether the payer will pay for your services or if the patient will be responsible for paying out-of-pocket.
VOBs are also required for figuring out patient copays. As you wait for complete payer reimbursement, these copays might help you preserve your cash flow. You can utilize VOBs to determine whether your patient must obtain pre-authorization from their insurance company before visiting you. Health maintenance organization (HMO) plans commonly demand that patients receive insurer clearance before seeing specialists. Therefore this arrangement is popular.
Codify your services
After patient interactions, grant access to your patient charts to the front desk staff or a third-party medical biller. You can use these charts to fill out your medical claims with the proper CPT codes. Depending on the services you offer, you might also need to include DRG codes and NDCs. ICD-10 and HCPCS codes from the 10th revision of the International Classification of Diseases (ICD-10) may also be necessary to provide.
Submission of claims to Insurance
The payer chooses whether to accept, reject, or deny your claim through a procedure known as adjudication. The adjudication procedure also involves calculating your refund amount if your claim is approved. Reimbursement isn’t always 100%; the payer may pay a portion of the balance due and postpone giving the patient the remaining balance.
The claims are sometimes disproved or refuted. Even while rejections are upsetting, they are frequently relatively simple to resolve. Resubmit your claim with any errors corrected. It’s harder to deal with denials. They might demonstrate a non-repairable deficiency in patient pre-authorization or inpatient coverage.
Improve the Medical Claim Billing Process
The best method to increase the cash flow is to extend extra care to the medical claim billing process, regardless of whether you are a new provider or an established healthcare practice. Although physicians’ first concern is patient care, many are new to the field and lack the expertise to manage medical bills. However, this does not imply that seasoned Providers are experts in claims processing since several of them lack the most recent hardware and software and personnel knowledge in the new healthcare reforms.
Here are 8 methods to streamline your organization’s medical claim billing process.
Immediately explain the collection procedure
For medical claims billing efforts to be more effective, open and honest contact with patients is crucial. Please explain to new patients their obligation to pay for the services received, which are not covered by the insurance companies. The information might be included in patients’ documentation before their initial consultation.
Updating and maintaining patient records
How can you anticipate managing claims invoicing accurately if you don’t have complete information on all of your patients? You must instruct your staff to verify each patient’s insurance information and demographics.
One possibility is that your patient has changed employment and is now covered by a different insurance company or a new spouse. If the nature of insurance has changed, a patient may upgrade to the most expensive plan with lower deductibles or a less expensive plan with significantly greater out-of-pocket expenses. Verify basic details, such as the policy number and subscriber information, at least twice (including the billing address for the health insurance company). These particulars must match the information given by third-party payers.
Prepare for Excellence
Your company will deal with various insurance companies with specific regulations. An insurance provider may require the inclusion of chart notes with claims for new patients to establish a primary care relationship. However, some insurance companies request chart notes to support follow-up care and unconventional treatment methods.
Your employee training programs should be updated and expanded to include elements allowing billing departments to access patient data and identify the applicable filing requirements quickly. Doing this will ensure that each carrier has the data needed to process your claims quickly when you submit them.
Suppose a practice handles claims internally or through an external medical billing and coding services vendor. In that case, having a system of checks and balances will increase first-pass rates.
Employ the perspective that every denial management solution is truly a learning opportunity to enhance the process rather than criticizing staff members for errors. For instance, relatively high denial rates may indicate that your team needs further training or that your existing workflow requires a different scrubbing method.
Reasons for Claims Denials
- Doctors who lack the necessary credentials
- You don’t have enough supporting paperwork.
- Your effective team building codes for products or services that carriers do not cover
If your practice keeps track of denial codes, you might discover easy steps you can take to boost performance. For instance, emailing daily billing codes and chart notes to the billing department can save time and improve accuracy. Similarly, it could be time to review your coding practices and your coverage verification process if claims for services deemed “non-coverage” are routinely being returned.
Delegate Your Most Difficult Collections
You and your fellow stakeholders may be hesitant to consider outsourcing work since you are a provider providing services to the community for a long time. But it’s wise to have an open mind, mainly when your revenue cycle’s effectiveness is at risk. Your employees are freed when you partner with a third-party provider of revenue cycle management services who can handle the more complex collections.
They will assist your patients in dealing with their unpaid bills by establishing payment plans and procedures to recover payments.
Enhance Quality Control
Indeed, reducing claim errors is essential to your practice’s financial health. However, the billing and collection procedure continues once a claim is accepted. Medical providers can keep a close eye on cash flow by posting and recording payments using generally accepted accounting principles.
By sending the billing team a deposit log for each receipt, you can increase the accuracy of account balances. The log must contain all the necessary details to guarantee proper posting and to make it simple for a reviewer to verify that the correct payment amounts were sent to the appropriate accounts.
This fundamental information should be recorded in a log:
- The patient’s name
- Invoice number
- The number on the check or cash receipt
- Payment due
- Referral reference number or service date
- Insurance company name
Follow Up on Delinquent Claims
How much money is being held back from being posted to your practice? Your response will reveal the percentage of past-due claims still awaiting service. At least few dedicated staff member should be employed to review account aging and identify which claims are not being paid on time.
After critically investigating old receivable accounts, you may find problems with patients’ or insurance companies’ communications.
Are your explanations simple enough for patients to comprehend? Is the company handling your billing and medical coding processing your claims quickly?
A more significant issue may be present if there are high delinquency rates. Reviewing past-due accounts regularly with an eye toward performance improvement will help you address these issues when they are still simpler to address in the early stages. It’s critical to put procedures and practices in place that assist your staff in filing claims quickly and effectively. A meeting on the subject might be necessary because it’s likely that there are some communication problems between you and the other parties.
Finally, by assessing the medical billing cycle from the initial patient contact through check deposit, you’ll be able to streamline the claims procedure, better capture reimbursements, and ultimately enhance profitability.
How do we help prevent paying late medical claims?
BMB advises you to take the following actions to prevent payment delays from medical claims as well as from third-party party insurance payers:
We maintain a log of billing and coding claim reviews
Based upon this payment schedule from Medicare and the EOBs (Explanation of Benefits) from all third-party payers, we monitor trends for each healthcare BPO provider. The difficulties generating denials and rejections for your practice are then identified by monitoring and evaluating these patterns.
We analyze billing monthly
Once a month, the team members that handle data entry, coding, documentation, billing, posting payments, assessing denials, and coding get together to discuss the following:
- Any current insurance new letters and notifications of any billing or coding changes
- Current practice concerns that are pertinent to the billing function
- A breakdown of how patterns from the claims review log are handled and their impact on the accounts receivable expressed as “dollars and cents” and as a percentage of error.
Getting services from a professional medical billing company is the best way to streamline and recover your bills on time. Claims need several technical protocols and meet industry standards to get payments.
One such regulation that guarantees high levels of security throughout the transmission of patient data is HIPAA. Process claims are submitted electronically to speed up the procedure and increase effectiveness.
The existing medical billing process is often so complex that invoices frequently take not just days but months to be finalized when patients present with a complex case or a significant medical history to be taken into account. Due to the challenges of balancing internal practice workflow with all of the demands from your claims processing vendors and external clearinghouses, the issue involves ongoing examination, even for the most routine treatments. You should be aware that your business has a variety of choices for streamlining the coding and billing procedure, which will speed up submission timelines and enhance your first-pass acceptance rates.