Improving Medical Claims Processing Through Technology

Understanding Medical Claims: What You Need to Know

Medical claims are an essential component of the healthcare system. They are the means by which doctors and hospitals get reimbursed for the services they provide to patients.

The medical claims process begins when a patient visits a doctor or a hospital for medical care. After receiving treatment, the provider creates a bill that itemizes the services and associated costs. This bill is then submitted to the patient's health insurance provider for payment.

The insurance provider reviews the medical claim to determine if it meets its criteria for reimbursement. If the medical claim is approved, the insurance provider will pay the provider for the services rendered, often with a deductible payment from the patient.

Medical claims can be complex and confusing, especially for those unfamiliar with the healthcare system's intricacies.

Challenges of Medical Claims Processing

Medical claims can be daunting due to the complexity of medical billing codes used for each procedure. Medical billing codes describe each aspect of the medical service provided to ensure correct billing, which can result in many lines of information on a claims report. The bill contains the details such as charges and fees and medical billing codes that represent the specific medical diagnosis and treatment provided.

The medical claims process can involve a lot of back and forth between the provider and the insurance provider. This process can be lengthy and time-consuming, resulting in frustration for patients and providers.

However, accuracy is critical when it comes to medical billing, as errors can result in the denial of the claim or payment delays. This is why hospitals and clinics often employ medical billing service providers to take care of the arduous process of filling out accurate claim reports.

Importance of Medical Claims Processing

Medical claims matter because they form the basis of how medical providers get paid for their services. With accurate and timely payment, medical providers could continue providing quality patient care. On the other hand, patients rely on medical insurance to reduce the cost of healthcare.

Unfortunately, issues of under- or over-reimbursement are not uncommon. They can lead to out-of-pocket expenses for patients when the treatment costs exceed the maximum coverage of their insurance plan.

What Are the Differences Between Different Medical Claims?

Several types of medical claims are used in the healthcare industry. Let’s quickly go through each of them:

• Professional Claims: Physicians and nurses submit professional claims for reimbursement of services provided to patients.
• Institutional Claims: Hospitals and clinics submit these claims to be reimbursed for patient services.
• Dental Claims: These medical claims are prepared by dental healthcare providers for reimbursement of services provided to patients.
• Vision Claims: These medical claims are filled out by vision healthcare providers, such as optometrists or ophthalmologists, for reimbursement of patient services.
• Pharmacy Claims: Such medical claims are submitted by pharmacies for reimbursement of prescription drugs provided to patients.
• Medicare Claims: These are claims submitted to the U.S. federal government's Medicare program, which provides health insurance coverage for eligible individuals over the age of 65 or with certain disabilities.
• Medicaid Claims: These are claims submitted to state governments' Medicaid programs, which provide health insurance coverage for eligible low-income individuals and families.

The specific types of medical claims used may vary depending on the healthcare provider, the type of services provided, and the insurance coverage or reimbursement program involved.

What Are the Types of Medical Claims Processing?

Paper-based is the traditional method of claims processing, where healthcare providers submit paper claim forms to payers for reimbursement. This process involves manual data entry and can be time-consuming and prone to errors. But is there a better way? Take a look.

Electronic medical claims processing

This is a more modern method of claims processing, in which healthcare providers submit electronic claims using standard formats such as HIPAA 837. This method is faster and more accurate than paper-based processing and is now widely used.

Real-time claims adjudication

This is a process where healthcare providers can submit claims in real-time and receive immediate feedback on whether the payer and the reimbursement amount cover the claim. This method can help providers identify potential issues with claims before submitting them for reimbursement.

Automated claims processing

This is a process where claims processing tasks are automated using software, which can help reduce manual data entry and improve accuracy. This method is becoming more popular as technology improves and can help reduce processing times and costs.

5. Claims auditing: This is a process where claims are reviewed for accuracy and compliance with regulatory requirements and payer policies. This method can help reduce errors and identify potential issues with claims before they are submitted for reimbursement.

As you can see, medical claims processing aims to ensure that healthcare providers are reimbursed for services rendered while also ensuring compliance with regulatory requirements and payer policies. The specific method used for claims processing may vary depending on the healthcare provider and payer involved.

Automation and AI in Medical Claims Processing

The use of automation and artificial intelligence (AI) is gaining importance in medical claims processing. Automating repetitive tasks such as claims validation, data entry, and fraud detection can reduce the time and effort required for medical claims processing.

AI-powered algorithms can also help identify patterns and anomalies, detect fraudulent claims, and flag potential errors, improving the accuracy and efficiency of claims processing.

Electronic Health Records and Medical Claims Processing

Electronic health records (EHRs) are increasingly being used by healthcare providers to store and manage patient health information. EHRs can also be integrated with claims processing systems, allowing insurers to access relevant patient information and streamline the claims process.

This integration can reduce the need for manual data entry, improve accuracy, and reduce administrative costs.

Blockchain Technology and Medical Claims Processing

Blockchain technology can potentially transform medical claims processing by creating a more secure and transparent environment. By creating a tamper-evident, decentralized ledger, blockchain can improve the security and trust of data involved in medical claims processing. It can also reduce administrative costs by eliminating the need for intermediaries and enabling faster payment processing.

Mobile Medical Claims Processing

As mobile technology continues to grow, insurers offer mobile apps that allow policyholders to submit claims and track their status on the go. These mobile apps can also utilize AI-powered chatbots to automate customer service, reducing the need for human intervention and speeding up claims processing.

Predictive Analytics in Medical Claims Processing

Predictive analytics is an emerging technology that uses data mining and machine learning to predict future trends and behaviors. In the context of medical claims processing, predictive analytics can help insurers identify areas where fraud is most likely to occur, allowing them to take preemptive action. It can also help insurers adjust premiums based on predictive modeling, making the pricing more accurate and fair.

How ClaimAction by Artsyl Improves Medical Claims Processing

ClaimAction by Artsyl is an intelligent automation solution that can improve medical claims processing in several ways:

• Increased efficiency: ClaimAction can automate manual tasks such as data entry, verification, and routing, which can reduce processing times and improve overall efficiency.
• Improved accuracy: ClaimAction uses intelligent capture and data extraction technology to accurately extract data from all fields and tables of claim forms, reducing errors and improving accuracy.
• Faster payments: By automating the claims processing workflow, ClaimAction can help accelerate claims approval and payment, reducing the time it takes for providers to receive payment for services rendered.
• Compliance: ClaimAction can help ensure that medical claims are processed in accordance with regulatory requirements and internal policies, reducing the risk of non-compliance and associated penalties.
• Scalability: ClaimAction is a scalable solution that can be configured to meet the needs of healthcare providers of any size. The solution is designed for small clinics, large hospitals, healthcare systems, and Business Process Outsourcing (BPO) companies.

Overall, ClaimAction can help healthcare providers streamline their claims processing workflows, reduce costs, and improve patient satisfaction by ensuring that claims are processed accurately and quickly.

Final Thoughts

As the healthcare industry continues to evolve, medical claims processing will play a critical role in ensuring the smooth and efficient operation of the sector. With the latest technology advancements, such as automation, AI, EHRs, blockchain, mobile claims management, and predictive analytics, medical claims processing is undergoing a transformation.

By adopting these technologies, providers, and insurers can streamline the process, reduce administrative costs, and improve the accuracy and effectiveness of medical claims processing.

FAQ

What is medical claims processing?

Medical claims processing is the process of submitting and managing healthcare claims for reimbursement. It involves submitting claims to insurance companies or other payers, verifying the accuracy of claims, and ensuring that providers are paid for services rendered.

Why is medical claims processing important?

Medical claims processing is important because it allows healthcare providers to receive payment for services rendered. It also helps ensure that claims are processed accurately and comply with regulatory requirements and payer policies.

How are medical claims submitted?

Medical claims can be submitted in a variety of ways, including paper-based forms, electronic claims submission, and real-time claims adjudication.

What information is required to submit a medical claim?

To submit a medical claim, healthcare providers must typically provide information such as patient demographics, diagnosis codes, treatment codes, and insurance information.

What is the typical timeframe for medical claims processing?

The timeframe for medical claims processing can vary depending on the type of claim, the insurance company or payer involved, and the specific requirements for claim submission. In general, electronic claims processing can be faster than paper-based processing.

What happens if a medical claim is denied?

If a medical claim is denied, the healthcare provider may need to provide additional information or submit an appeal to the insurance company or payer. The denial may also be reviewed for potential errors or compliance issues.

How can medical claims processing be improved?

Medical claims processing can be improved through the use of technology, such as automated claims processing and real-time claims adjudication. Improved communication and collaboration between healthcare providers and payers can also help streamline the claims processing workflow and reduce errors.

What are some common challenges with medical claims processing?

Some common challenges with medical claims processing include inaccuracies in claim submissions, delays in claim processing and reimbursement, and compliance issues with regulatory requirements and payer policies. These challenges can result in financial losses for healthcare providers and patient dissatisfaction.