While the core mission of healthcare providers is to deliver care that quality, making sure on-time and accurate reimbursements for these solutions is equally important. The process of claim submission plays a crucial role when it comes to the financial health of a practice. An efficient and well-mitigated claim submission workflow directs you to faster accounts receivable turnover, enhanced cash flow, and a concrete revenue cycle performance overall.
A Little Something About Claim Submission Process in Medical Billing
Submission of medical claim is the procedure by which a healthcare practitioner provider formally asks for a reimbursement from a patient’s insurance carrier for solutions rendered. Each claim includes standardized medical codes primarily CPT (Current Procedural Terminology) codes that accurately represent the procedures or treatments performed during the patient encounter. When a provider is submitting a clean claim, that all of it is free of errors the claim is then processed more smoothly, causing a faster adjudication and quicker payment within the accounts receivable cycle.
What To Expect After A Claim Submission?
In today’s world, a high number of medical claims are submitted digitally, optimizing the reimbursements process and reducing administrative delays. However, in some cases – such as somepayer requirements or system outrages – submission claims on paper might still be required. Once a claim is submitted, it enters the adjudication process, during which the payer evaluates the claim to determine its status: approved, rejected, or denied based on coverage, accuracy, and compliance with policy guidelines.
The claims accepted are then paid to the providers, even after knowing that the reimbursement rate is not going to be 100 percent of whatever the provider charges. But in case of rejected claims, they’re often returned back to the provider in case of errors for correction.
Similarly, denial claims also returned to the provider with no payments. Rejected and denied claims are common. For example, Medicare Advantage denies an average of 8 percent of claims, and some payers initially deny up to a third.
Some Easy Steps For Achieving Clean Claim Submission Rate
Cross Checking Patients Information
Patients’ information errors can be the most frustrating reason for a medical claim to be denied. You can avoid such types of errors by keeping your patients information updated within your electronic health record (EHR) and rechecking this information everytime patient visits.
Follow a stringent prior authorization process
Keeping up with payers to make sure that certain treatments are covered cna be time consuming but is also necessary. Prior to a patient being scheduled for a visit, be sure to obtain pre authorization. It is highly recommended to obtain prior authorizations at least five days before the day the service is performed. This lowers the likelihood of claims denials substantially.
Keeping up with the latest medical coding protocols
Medical coding protocols are revolving remarkably, yet it is becoming a challenge for in-house staff to staff fully up to date especially when it comes to balancing multiple administrative responsibilities. For this specific reason, outsourcing medical claim billers is a more efficient option and reliable solution. A team that is dedicated to billing solutions focuses mainly on the nuances of medical coding and billing, ensuring they remain current with regulatory updates, coding changes, and payer requirements. This expertise helps reduce errors, improve compliance, and optimize reimbursement outcomes.
Make sure to use the right modifiers
Payer-specific guidelines for using modifiers can vary significantly, making it crucial to understand which modifiers are acceptable by each insurer before submission of claims. Application of incorrect or unrecognized modifiers can cause flagging the claim in the payers system, leading to denied or delayed payments. Maintaining clean claims and optimizing payment efficiency depend on precise modifier assignment based on specific payer requirements.
Quality check of performance prior to claims submission
Quality checks are a crucial last step before filing a claim. A number of items should be reevaluated during the check, including patient demographics, medical codes and modifiers used, and other relevant information. The term “claims scrubber” is used by some medical claims billing software to “scrub” each claim for errors prior to submission.