Critical Elements of an Effective Claim Management Process

Critical Elements of an Effective Claim Management Process

Effective claim management is critical for obtaining correct reimbursement at the right time and reducing claim denials.

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Claim management refers to organizing, submitting and processing medical claims relating to patient diagnoses, treatments and medications. This is critical for efficient medical billing and increased cash flow in any medical practice. Effective claim management streamlines claim billing, increases the number of clean claims submitted, reduces claim denials, ensures timely and accurate payments for patient services from health insurers and improves staff efficiency. Here is an overview of critical elements of an effective claim management process.

Pre-registration This includes the following procedures: 

Collecting patient demographics and health information correctly.

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Insurance verification to determine whether the services provided will be covered by insurance. This includes verifying the coverage and applicable deductibles/co-pays/co-insurance.

Patient Check-in A smooth patient check-in is crucial for meeting the requirements of each patient systematically. Check-in involves copying the patient’s health insurance card, especially the crucial details including the patient’s policy number and verification of insurance information to confirm whether the patient is eligible for insurance coverage.

Documentation You should maintain and update the patient’s medical history, symptoms, diagnosis and treatment plan including laboratory results and x-rays ordered. Proper documentation of services provided is essential for effective claim billing. This is because some patients may relocate or visit several medical facilities, there may be complex coverage policies for some patients and some others may require follow-up care. For effective claim management in these cases, it is inevitable to keep track of all medical visits, treatments

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and expenses and this is possible with accurate and complete medical documentation.

In short, proper documentation is crucial for filing clean claims.

Medical Coding Once the documentation is complete, you should assign the correct ICD and CPT codes (diagnosis and procedural codes) depending upon the coverage policies and the latest federal guidelines. Make sure that the documentation of the office visit is consistent with the diagnosis and treatment plan. Note down whether a complete physical examination is carried out at the subsequent office visit. Get help from experts in this field to avoid the risks of undercharging, overcharging and claim denials.

Patient Checkout Before the patient leaves your office, collect any additional information required and record it in the patient charge sheet. The following procedures are also done at this stage. 

Scheduling follow-up

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Collecting co-payment or deductible

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Making any special payment arrangements

Auditing and Review Make sure that all codes are assigned according to the federal guidelines as well as coverage policies before creating a claim for the patient. Proper auditing and code reviewing is essential for that.

Claim Generation and Review A claim is generated after entering the codes and their corresponding fees accurately.

You should review those claims for accuracy with the help of billing specialists before submitting them to the health insurers. www.outsourcestrategies.com

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Claim Processing, Adjudication and Payment Once the claim is submitted to the insurer, they will review the claim, approve and route the payment while sending a copy of the EOB (Explanation of Benefits) to the physician's office and original EOB to the patient. Thoroughly review the EOB to ensure proper payment is received.

A/R Follow-up and Denial Management If the insurer is not processing your claims in a timely manner and you have accounts receivable (A/R) or unpaid claims, you can employ a collection team to follow up with the insurers to collect the amount as quickly as possible. At the same time, you can conduct another audit to review/correct errors in the rejected claims and resubmit them to the insurers.

Payment Posting The collection team should verify the payment according to the contract and post in accounts receivable.

Appeals If your collection team finds the payment inappropriate, you can investigate it and file an appeal against the denial. However, you should pursue an appeal properly with the help of experts to highlight the evidence and get the desired results.

Tips for Submitting Clean Claims * Clearly describe the services rendered in the patient’s chart with accurate demographic information such as the patient’s date of birth, insurance identification number, provider’s NPI and other necessary details. * Your documentation should support the level of service or procedure provided.

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* The CPT and ICD codes in your claims should correctly reflect the documentation for the visit, especially global fee periods of surgery, modifiers and medical necessity.

It is a time-consuming and hectic task for busy practices to maintain patient records, interact with insurers and issue invoices for medical services provided. Outsourcing these tasks to a reliable medical billing and coding company is a practical option that will ensure you more time to spend with your patients, improve the quality of healthcare services and improve your revenue inflow.

www.outsourcestrategies.com

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