The Life Cycle of a Medical Claim (and Why you need to take a closer look)

The medical claims process can be cluttered with complex nuances that leave plenty of room for error at both the clinical level and the billing level. Mistakes can delay payment unnecessarily, adding months to a claim’s life cycle. Understanding and identifying what contributes to claim mistakes early in the process is critical to decreasing errors and improving collections.

The trouble can start as soon as a patient calls to schedule an appointment. Staff should verify insurance, confirm their copay or coinsurance, as well as review whether they have an open balance to settle.  It is prudent to verify or update the demographic and health insurance information you have on file.

Insurance companies benefit from such mistakes. By taking the time to identify problem areas, you can prevent them from capitalizing on weaknesses in your billing process. Carve out a few hours to sit down with your staff and examine every point at which a decision is made regarding a claim. Then address the flaws in those procedures and train your staff accordingly.

You can improve your claims process by reviewing these five areas:

  1. Data entry and spelling. Often, a small misspelling or the omission of information will result in a denial.  Data and charge entry need to be carefully entered and reviewed.  Incorrect patient information is the number one reason for claim denials.
  2. Do your patients fully understand their benefits? Most don’t—especially with insurance companies changing them so often. Make sure your front office staff takes a few minutes to explain prior authorization and insurance benefits to patients.
  3. The efficiency of the collections process. Does your staff collect the co-pay, co-insurance or open balances while patients are in the office? Doing so can increase revenue overnight. In many practices, patients represent almost 25% of the practice’s revenue. For patients who have a balance and cannot pay in full, this is a good time to establish a payment plan.
  4. Accounting for every physician in your practice. Many times, a claim is denied or paid at an out-of-network rate simply because of improper credentialing.  Every physician should review, update and maintain their Proview/CAQH details on a regular basis to ensure proper credentialing with payers.
  5. Bill claims daily and make sure billers are submitting clean claims.  Clean claims get paid the first time around and stand up to a potential audit.  Electronic claim scrubbing catches errors before sending so you can correct mistakes in minutes instead of weeks.

By addressing the trouble spots in these five areas early, you can quickly improve your bottom line. Don’t you owe it to yourself and your practice?

AssuranceMD’s comprehensive revenue cycle management solution addresses every aspect of a medical claim.  View the video below to see where could you benefit from professional assistance?

To learn more about enhancing your billing process and improving your financial performance, contact us to schedule a free consultative call.