Medical claims processing is a systematic approach through which physicians and other healthcare facilities are getting paid in a timely fashion. Claims processing involves a series of consecutive steps including preparation of claims form, submission to the medical insurer and thereafter following up on claims. The process actually starts before a patient visits the provider’s office. He simply calls for an appointment by providing some basic information. Then he arrives at that healthcare facility to get the healthcare services, it can be a wellness check-up or a major surgery. After receiving medical care and treatment, it is the responsibility of the patient to pay off a deductible, an amount that he is bound to pay before his medical insurance commences. So, it’s time to prepare the medical claim depending upon the services provided to the patient.
Procedure of medical claims processing
The healthcare providers are always active in claims processing and thus interact with the medical insurer to keep reimbursement flowing. Committing a mistake at any stage of claims preparation may lead to denied claims and hence disrupting cash flow in the provider’s office. Most of the denied claims are result of the misplaced diagnosis, wrong medical details such as reported gender and incorrect or other uncovered medical services. It is very much important to completely understand the specified inclusions, conditions and exclusions in the insurer-provider contract.
For better understanding, we can break down the whole procedure of medical claims processing into four sections:
Probably this is the stage where various health insurance problems originate and later give a big trouble to both the provider and insured person. Claim denials and underpayments would be the ultimate result if the terms and conditions of health insurer contract are not carefully negotiated at the beginning.
Processing error-free medical claims is crucial and it involves lots of official procedures and directions that need to be followed when a patient visit to the healthcare facility.
Step 1 Preregister Patient
Step 2 Determine Patient’s Financial Responsibilities
Step 3 Patient’s Check-in
Step 4 Patient’s Check-out
Step 5 Review coding compliance
Step 6 Check billing compliance
Step 7 Prepare and transmit claims
Step 8 Monitor Payer Adjudication
Step 9 Generate patient statements
Step 10 Follow up patient payments and handle collections