What is Medical Claim Processing? What are the Challenges Involved?

Medical claims processing is the procedure by which a healthcare provider processes bills for submission to healthcare insurance companies. These bills detail the cost of treatment to the insurance policyholder. It comprises assigning codes and the associated costs. Insurers examine the medical codes, determine the necessity of medical care, and reimburse the healthcare provider accordingly.

Medical claims processing is handled by skilled professionals with inside out knowledge of coding. The bills are created and submitted as per HIPAA guidelines. Many providers seek the help of clearing houses to sort claims related issues. A clearinghouse is a third party vendor that works and handles everything between the provider, policy holder and the Insurance Company. It organizes the bills, spots and removes errors, and submits them with the payer for reimbursements. After the reimbursement, it collects the EOB on behalf of the healthcare provider. An EOB or explanation of benefits shows details like a list of payment made, date of, and other information.

Challenges in Medical Claiming Processing

• A big challenge in claims processing is establishing patient eligibility. Claims processing becomes an issue when a provider provides service for which the person was not eligible. This generally happens when a policy gets updated, or coverage is no longer valid.

• Another challenge is to provide accurate patient and treatment information. Providing incorrect information in a claim can lead to rejection of the claim. Some inaccuracies like typographical error can be fixed but others can lead to delays if not denials.
• Yet another challenge is incorporating the correct codes. Putting incorrect ICD codes can lead to the rejection of claims. This is because every diagnosis has a code assigned to it and a wrong code means the diagnosis has not been carried out.

How Can You Improve the Process?

The process can be improved with the help of electronic submission and data analytics.

• Electronic Submission of claims is a low cost method of claiming reimbursements. It helps in timely reimbursements because the process eliminates chances of errors. This is the most popular form of medical billing because it frees the payer from paperwork. All the information related to the process like claim status and payment date can be viewed online.
• Analytics help healthcare providers identify errors in the overall billing process. For instance, it can be used to know if the data submitted is accurate and complete. It helps to correct general information such as ICD Codes, patient’s name, and insurance ID for clean submission. It is also deployed by providers to identify compliance to rules and regulations. By banking on analytics, providers can handle complex claims with ease.

Conclusion

Medical claims process can also be challenging for many other reasons. Some of these can even be unforeseen. No matter what the challenge is, to ensure effective processing of claims one should always bank on a well-defined process and advanced claims processing technology.