Revenue Cycle Management Blog | GroupOne Health Source

What are the Elements of a Highly Efficient Claims Process?

Written by Kaitlyn Houseman | August 16, 2016

Because there are typically multiple parties involved in a medical care claim, the process quickly becomes quite complex, which lends itself to a variety of errors caused by both humans and technology. Developing an efficient claims process is crucial to the success of your medical practice, and the process begins before any claims are even submitted.

Today's healthcare practices must have procedures in place that start the minute a patient contacts the office, and that continues through the entire claim submission process and beyond. In order to avoid as many claims issues as possible, it's important to be prepared for all of the challenges that may come up during the process.

By adhering to industry standards at all times, and developing procedures that are in line with the industry's best practices, healthcare administrators can create a claims process that works for the healthcare provider, the insurance company and the patient.

What to Do Prior to Claim Submission

There are several things you can do prior to a claim submission that will help make the rest of the claims process smoother.

Prepare the insurance company for what's expected to be reimbursed and make sure the the patient is aware of what portion of the service they will be financially responsible for. This will make the entire process go a lot faster.

Verify patient eligibility before every appointment to cut down considerably on the number of claims which are denied completely or partially. In some cases, it makes sense to complete prior authorization before performing any procedures in order to verify what will or will not be covered by a patient's insurance provider.

[Also: Top 5 Causes of Recurring Claim Errors]

Successfully Completing the Electronic Claims Process

Once the patient receives treatment, the healthcare provider is responsible for submitting the claim to the payer which is typically the patient's insurance company.

Once the payer receives the claim information, they determine which services are eligible for reimbursement based on the information provided by the healthcare facility's medical billing specialists.

While claims can be submitted manually, it is extremely beneficial (and increasingly more common) for medical billing specialists to electronically submit claims. When all patient data is recorded using the appropriate software, it allows data to be easily accessed at any time.

However, there are still instances where paper claims are submitted, therefore it is important for medical billing and coding specialists to be educated on both electronic and manual claims processing.

Claim Scrubbing Software

Additionally, because different healthcare providers and insurance companies may use different software to keep their records, it is crucial for billing specialists to code with maximum accuracy and specificity to avoid data entry errors. The smallest of errors could delay the claims reimbursement process significantly, so it's important for healthcare professionals to be well-educated and detail-oriented throughout the process.

There are a variety of claim scrubbing software tools available today that assist healthcare billing specialists with submitting the most accurate claims possible. These tools help to validate the information that is submitted by comparing it to standard coding rules set forth by Medicare, Medicaid, and the like.

[Also: Some Health Insurance Companies Automatically Enrolling Patients in Medicare Advantage Plans]

Effectively Following Up On Claims

After a claim is submitted, it is important for the healthcare provider to follow up regularly with the insurance company on the status of the claim. By carefully tracking submitted claims throughout the entire process, using advanced software and well-outlined follow-up procedures, healthcare professionals can stay on top of any potential issues, such as incorrectly filed claims due to data entry errors, incorrect coding, etc.

By following these medical claims guidelines as closely as possible, your healthcare practice can create a more efficient claims process, leading to fewer claim denials and higher reimbursement rates.