Claims Processing

Claims processing plays a pivotal role in the healthcare revenue cycle. From preparing for a patient’s visit to submitting claims and managing payer interactions, each step ensures the proper flow of revenue. However, achieving the revenue you deserve requires more than just routine processes—it demands a strategic approach. Let’s explore the key stages of effective claims processing.

1. Preparing for Care

Effective claims processing begins before the patient even arrives. Preparation ensures your practice is ready to handle the financial aspects of patient care. Here’s how:

• Check Insurance Eligibility: Even returning patients may have changes in coverage due to factors like job changes. Regular eligibility checks can help avoid claim denials and ensure your practice is prepared for any changes in a patient’s coverage.

• Obtain Prior Authorization: For certain services, prior approval from the insurance provider is mandatory. This helps avoid unnecessary denials and ensures the services provided will be covered.

• Offer Patient Cost Estimates: Patients want clarity on their healthcare costs. Providing accurate cost estimates based on insurance coverage can improve patient satisfaction and boost revenue by collecting payment upfront.

2. Converting Care into Codes

After the patient visit, medical coders and billers translate the services provided into standardized medical codes. This ensures the healthcare provider receives the correct reimbursement for services rendered.

• Medical Coding: Medical coders review clinical documentation and translate it into CPT, ICD-10-CM, and HCPCS Level II codes used in billing.

• Medical Billing: Billers use these codes to create and submit claims to insurance companies. They also manage follow-ups to ensure claims are processed and reimbursed correctly.

• Claim Scrubbing: Before claims are submitted, they are reviewed for errors by a clearinghouse. Catching errors early reduces the risk of denials.

3. Insurance Adjudication

Once a claim reaches the payer, the insurance adjudication process begins. The insurance provider reviews the claim to decide whether it should be paid in full, partially, or denied.

• Adjudication Process: Claims are assessed for accuracy and compliance with payer policies. Issues like incorrect policy numbers, lack of medical necessity, or misaligned diagnosis and treatment codes can lead to claim denials.

• Lesser-of Clause: Sometimes, insurance pays the billed amount instead of the contracted rate due to clauses in provider contracts. Understanding and negotiating these clauses can prevent revenue losses.

4. Managing  Denials and Underpaid Claims

Denied and underpaid claims can be a drain on time and resources, but they don’t have to be a lost cause. Reworking denials is essential to recovering revenue that would otherwise be lost.

• Financial Impact of Denials: Denied and underpaid claims can result in prolonged accounts receivable (A/R), lost reimbursements, and increased write-offs, costing practices up to $100,000 per month.

• Reworking Denials: With modern technology, healthcare providers can rework denials more efficiently, reducing the burden on staff and increasing revenue. Meritmaxx Healthcare 24/7, for example, offers tools to manage payer contracts, eligibility checks, and provide accurate cost estimates upfront.

Maximizing Revenue with Merit Maxx Healthcare 24/7 

Merit Maxx Healthcare 24/7 integrates seamlessly with your EHR to provide real-time insights into your practice’s performance. From eligibility checks to managing denials and underpayments, we help you streamline your revenue cycle and boost financial outcomes.