What is Medical Claims Processing and Billing?

21 August 2022
What is Medical Claims Processing and Billing?

The core pillar of any healthcare insurance provider is the medical claims processing and billing: it is the starting point where the medical data gets processed by the insurance business through close scrutinizing, receiving approval, and payment for the received claim. To obtain the rightful compensation, it is suitable for the companies and employees to make a proper investment in the insurance processes. By doing so, the medical insurance claim processes enable them to receive prompt compensation and payments.

In case the healthcare provider is new, it is only suitable for them to ensure much care is provided to the medical claims processing sector as it helps them enhance the cash flow. It is well-known that patient care and excellent patient experience are physicians' most significant focus areas. As these Physicians are new to the industry, they might not have sufficient experience handling medical billing procedures and claims processing. Hence it is essential to allow an experienced and knowledgeable team to handle this complex process efficiently to avoid any errors resulting in claim denials.


The Significance Of Medical Billing

It is a strenuous and lengthy procedure containing the submission of claims. It requires consistent follow-up routines with the various insurance companies to collect on-time payments for the medical care and services provided by the healthcare provider.

Any medical care related service provided to the patient gets translated into a claim through medical billing. It is essential to consistently follow up with the insurance company as soon as the claim gets prepared and submitted. This way, you can ensure that the healthcare provider would receive the rightful reimbursement on time for the various medical services they have performed for the patient. By doing so, the healthcare organization's revenue cycle performance gets enhanced.

The Vital Role Of Medical Claim Processing In Healthcare

Medical claim processing is a specific procedure performed by the insurance provider's company to thoroughly scrutinize the requests for medical claims to ensure sufficient data is available and that they are validated and authentic. After this procedure, either entire or part payment gets reimbursed to the healthcare provider by the insurance provider's company. If the claim gets identified as invalid or duplicated, the insurance company immediately denies the medical claim request.

This process begins immediately after a medical claim request gets submitted to the insurance provider company. The medical billers within the health care facility submit the claim requests directly at times, and there are times when it gets submitted through a clearing house.


The Different Steps Involved In The Process Of Medical Insurance Claim Processing:

1. When a patient visits the medical clinic or any healthcare facility, an appointment gets booked. The respective medical services rendered are coded and submitted electronically through email or paper.

2. Once the medical claim paper is received, either they get scanned or entered manually into the system.

3. The first stage of review gets carried out where the spelling and the dates are verified to see if duplicate information is present.

4. Track the patient in the system and ensure they were under insurance coverage right at the time of the medical service.

5. Based on the patient's insurance plan, need to review if the physician and the healthcare facility get covered within their insurance network.

6. Price negotiation gets done. It determines how much the physician gets paid, what amount will go on to the insurance provider, and the amount the patient ought to pay.

7. A careful verification gets done to check on the benefits covered and not covered for the patient.

8. Suppose there are any requirements to carry out specific medical procedures. In that case, the patient's eligibility under their insurance coverage gets carefully verified to determine if there is a need for the particular medical treatment.

9.Mainly need to evaluate the quality assurance to rule out if there are any fraudulency or abnormal charges.

10.Following this, the healthcare provider/physician gets paid.

11.At this stage, a detailed explanation of benefits (EOB) is not precisely a bill but a particular document containing the exact details of the medical services covered and those not under the insurance coverage to the patient. It helps them to get a rough idea of what they can expect on their bill.

12. The patient is intimated and gets billed for those medical services not by the insurance company.


Possible Challenges In Health Insurance Claim Processing:

The recent insurance claims process has become tedious and complex with the consistent addition of data and variables. Here below are some of the possible challenges in processing health insurance claims.

• Huge amount of data

• The chance for errors is high, owing to many touch points in handling the claims

• The constant change in the customers' expectations

• Time delay in resolving the claim

• Higher costs involved in determining the claims

• Advances in technological growth

• Difficulty and shortage in identifying the right workforce

• The impact caused by the inefficient claims management legacy systems


Simple Steps To Enhance And Streamline The Process Of Medical Claim Billing:

These simple steps, when followed rightfully, enhance and streamline your healthcare organization's complex process of medical claim billing.

• Transparent communication with the Patients

• Consistent maintenance of the patient files with prompt updating

• Automated Functions

• Expanded Employee Training

• Monitor and identify the denials

• Outsourcing the collections

• Constant review of delinquent claims

Choose BIS To Enhance And Streamline Your Complex Process Of Medical Claim Processing And Billing:

For handling the complex and tedious medical claims processing and billing, it is required for the team to be exceptionally skilled in paying attention to fine details. They must be highly knowledgeable to understand, interpret, document precisely, and consistently track exhaustive medical information quickly while maintaining strict patient confidentiality.

Business Integrity Services' proficient team of highly knowledgeable staff has many years of experience handling these complex and strenuous processes. Their hands-on experience helps you relax as they efficiently enhance and streamline your most crucial medical claim and billing process. Our team's conducive plan steers you clear from the errors that result in claim denials. Using our latest software makes the tedious process simple, and you can enjoy a hassle-free method of handling these medical claims and billing.

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