Claim Processing in Healthcare

Claim Processing in Healthcare


According to research sources, bad practice in medical billing within the US alone could leave about $125 billion of revenue to be thrown away every year! An experienced Medical Billing Company can help you claim processing in healthcare error-free, increase your profits, and decrease the number of claims denied.

RCM procedure begins with the front desk confirmation of the insurance documentation of the patient through the correct billing and coding process and submission of the claim processing in healthcare and follow-ups with insurance companies, and the resubmission when the claim is rejected or denied. It is the process of filing claims that is the most crucial for any healthcare or medical service provider and could have an enormous effect on the financial results of their business.

Typical Claim Submission

Regular refilling of a claim submission can cost up to 25 dollars per case (few industry sources suggest an even larger figure) and makes claim processing in healthcare adjudication an expensive option. Thus, the more efficient your workflow for claim submission is, the higher your first-pass rate for payment and the less time-consuming your billing time will be. In addition, according to sources, for group practices, the standard rejection rate for benchmarking is between 5 and 10 percent.

Medical Insurance Claim

The reports have indicated that as high as eighty percent of all medical invoices are void of mistakes. They could be as simple as a misspelling or omission of a patient’s name, or not checking that the patient is eligible under the insurance coverage, or even a change in a digit in a code. Additionally, the complexity prevalent in healthcare regulations, specifically medical insurance claims, and the procedures utilized in how medical services are paid for and collected often delay ensuring that claims are dealt with quickly.

Points to ensure an efficient Processing of Error-Free Claims to increase the profitability of your medical practice

A competent front desk staff that is skilled and well-versed in both Medstar Billing and other insurance companies’ intricate details and coverage is crucial when you first start using a claim processing in healthcare Management procedures.

The next step is to find reputable billers and coders familiar with the intricacies of the ICD-10 codes and the appropriate modifiers to use. Billers must be on guard in examining and processing claims since they are the most crucial components of your workflow to manage claims. Claims employees who can effectively monitor claim submission and present well-documented proofs for rejections and denials.

In-house or outsourcing the process of processing claims can assist in speeding the process of reimbursement for claims to increase profitability for any medical facility. It is, therefore, crucial to perform codes and medical billing services with precision because the denial or rejection of the claim is contingent upon errors in the data and important code errors.

Claims Understanding the Revenue Circle

For hospitals and physician practices to ensure that they are paying their claims, they first need to understand how the various components of medical insurance claim management impact the amount of reimbursement.

“Whether you call it a revenue cycle or protecting your reimbursement, success will depend on making many improvements simultaneously,” says Nalin Jain, Director of Delivery of Services Advisory Services CTG Health Solutions. “It’s not just one small thing that you fix, but making several improvements and making them simultaneously through the process from pre-care to zero balance.”

According to Jain, the healthcare institutions and providers who are successful at reimbursement can consider how the different components of the patient-provider interaction are integrated into the overall revenue cycle. However, they also have the potential to create gaps that could lead to losses or risks.

“When you compartmentalize your practice or your hospital across these five areas,” Jain adds, “you’re able to address within each of these components what is working and not working, what are the industry standards, where are your peers compared to where you are, and what you need to do to get to the next stage and then beyond that.”

To put it simply, the process of improving reimbursements starts with taking a look at the situation. Jain suggests that practices of physicians and hospitals pay particular attention to three major functional areas: technical, financial, and operational.

The financial aspect examines account receivable (A/R) and its collection rate metrics denials, denials, and the management of denials. The technical aspect considers processes, systems, and processes through all aspects of the patient-provider relationship. Finally, the operational aspect considers the relationship between the staff, vendors, and workflows.

Based on the magnitude of the healthcare institution and the number of analyzed processes, the evaluation can range from a few months to several months. Once it’s completed, hospitals and physician practices will have the ability to develop an improvement plan and benchmarks to gauge how they perform against.

Technology certainly has a role in assisting in improving the claim processing in healthcare and reimbursement rates. However, it’s certainly not a replacement for the process responsible for introducing or enhancing errors that cause bills to be unpaid or overpaid.

Only when all of the components that make up the revenue cycle are in sync will the flow of reimbursements be predictable.

Identifies key Stakeholders and The Activities in Claims Processing

Successful claim processing in a healthcare operation consists of skilled employees and well-controlled procedures. The revenue cycle that claims processing is only one aspect that can be influenced depending on the structure of the healthcare institution and the billing system utilized by the health care system, hospital, or doctor practices.

Here’s an outline of individuals and the activities that are part of the hybrid billing model, which blends both central and decentralized billing models:

The Activities and Personnel of the Hybrid Billing Model

To ensure that your income cycle runs smoothly and for improving claims reimbursement are identified promptly, Leaders from various departments within a healthcare company must communicate regularly, with certain meetings happening more often than other meetings.

Tackling Claims Processing Bottlenecks of Payment Management 

Healthcare facilities of all sizes are in a difficult position in terms of reimbursement. While reimbursement is beginning to shift from value to volume, the bulk of their current revenue is dependent on the fee-for-service system. The solution to this question requires looking at the key factors that affect the revenue cycle of professionals and ways to develop structures that help improve efficiency in the billing process and management of claims.

That is particularly important when increasing provider consolidation, where larger organizations such as health care systems and hospitals purchase or join the independent practice. In this present environment that is the case, organizational efficiency is crucial to reducing waste or loss in your revenue stream.

In a model that is decentralized in its billing, it is the case that most billing processes are performed and managed at the place that provides the services (i.e., every practice has a small-sized company office). The positive side is that it allows businesses to have local control, close connections with doctors and patients, giving patients a sense of “ownership,” and quick resolution of errors attributed to physicians. But, on the other hand, it can result in different standards and processes as well as inefficiencies in staffing.

A regular, Choose Medstar Billing Services for Claim Processing in Healthcare.

We provide our experts’ professional services for claim processing in healthcare. Our staff at Medstar Billing Services follows up with you on your claim processing in healthcare. It conducts a thorough analysis and resolutions to ensure the whole process. We are aware of the technicalities of claim processing in healthcare.

Contact us now at 

Phone (407)337-5901