Guide to Outsourcing for Physicians

A medical billing claim is a document that a medical practitioner submits to a health insurance company. It contains Current Procedural Terminology (CPT) codes that define medical services you deliver to the patient. The medical codes represent the service provided by a practitioner, including diagnosis, process, medical gadgets, pharmaceuticals, and medical transportation.

How Does It work?

When providers file a claim, they include all applicable medical codes and charges for that visit. Insurance companies evaluate medical codes to decide how much they would repay providers for their services. Payers may quickly assess the services you performed and whether the patient is covered by using CPT codes. The final point is whether the patient’s benefits will result in the payer completely refunding you or delaying some payment.

Life Cycle Of A Medical Billing Claim  

Medical claim submission is a crucial process in medical billing. Understanding the stages of a medical claim’s life cycle is essential for reducing mistakes and increasing collections. Following are the critical milestones in the lifecycle of a medical claim.

Data Entry Phase

Manual or electronic data entry is the initial stage in the medical claim process. Data is entered, checked, and categorized during this process. Data contained in demographic and insurance information in this stage.

Editing Phase

The process goes on to revising or suspending claims step after entering and verifying the data. MITS changes the claim under business regulations, and it may be suspended or denied at this point. The MITS identifies third-party liability, claims may be refused during this phase, or if the claim is approved, it moves towards the cost avoidance phase.

Pricing Phase 

MITS analyses the rates during this phase to compute the final payment according to prior authorized rates. Claims that need manual pricing are placed in the delayed claims phase.

Audit Phase 

In this stage, service data is cross-checked against earlier claims by the same receiver and other facts for the same claim. Denials might occur at this level due to duplicate services, service conflicts, or service restrictions.

Disposition Phase

In this stage, claim is assigned a status of paid, suspended, or refused. Suspended claims are reviewed further and either paid after data correction or refused. After data repairing, the claim must go through all claim lifecycle steps again. If a claim is rejected during the disposition phase, it is formalized and moved to the recipient’s denied history record.

Reimbursement Phase

This step involves the transfer of funds to providers. If MITS successfully processed a claim and reached the paid status, payment is delivered to the provider. The last stages in the lifecycle of a medical claim includes updating scanning and paper-based claims in MITS and posting payment to the provider’s account.

Accurate patient data collection and tracking of the lifecycle of a medical claim are critical in establishing effective revenue cycle management.

What Is Medical Claims Clearinghouse?

A medical claims clearinghouse operates as a link between healthcare providers and payers. Medical claims are sent to a clearinghouse by healthcare providers. The medical claims are then scrubbed, standardized, and screened by clearinghouses before being sent to the payer.

This procedure helps eliminate medical coding mistakes and the time it takes to secure provider payment. The payer may reject a claim if it contains medical coding errors or fails to fulfil formatting criteria. This indicates that the claim would be resubmitted, causing provider reimbursement to be delayed.

Clearinghouses prepare medical claims data to meet the specific needs of each payer. This type of data standardization aids payers in streamlining their medical billing process.

Why are medical claims denied?

Claim denial has a negative impact on cash flow and practice efficiency. Eliminating rejections speed up the revenue cycle and boosts practice profitability. Here are the following points that why the claim is denied.

  • Duplicate claims 
  • Coding errors 
  • Inaccurate patient data 
  • Filing claims after deadlines 
  • Insufficient medical information 

 

Options After Your Claim Is Denied 
Appealing The Decision 

When an insurance company declines your claim, it does not mean the end of your claim. You have the option to submit an appeal challenging the denial. It is strongly recommended that you consult with insurance claims professional to manage your request to avoid missing critical details. In some cases, you may only have 30 days to file an appeal, making it even more important to work with a lawyer.

If your actions to appeal and resolve the problem fails, your next step will be to file a lawsuit against that insurance provider. Insurers despite going to court when their case is made public, so don’t be shocked if the insurance company in issue attempts to renegotiate a payment after your lawyer files a lawsuit. If your case needs to go to trial to be resolved, it will be up to the judge or even a jury to determine whether the decision to deny your claim was correct or incorrect.

How Can we handle Medical Claims Billing Process?

Our medical claims process enables us to manage your claim in the following steps thoroughly:

  • Check for coding and billing mistakes.
  • Send you an EOB (explanation of benefits).
  • Pre-adjudicate the claim to ensure its accuracy.
  • Submit the processed claim to the insurance carrier.
  • Provide you with claim history.
  • Review denied claims and re-adjudicate them as recommended to get them authorized. 

Our efficient medical billing and medical claims processing results in fewer denials and less work from you. Our expertise to appeal rejections and resolve various challenges with insurance providers to guarantee that you are correctly reimbursed.

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