The medical claims processing system is a complex arrangement that involves insurance providers, healthcare providers, patients, and third-party administrators. When a patient receives medical treatment, the associated costs and paperwork must be accurately reviewed and reimbursed according to the patient's health insurance plan. This requires detailed information exchange between all parties involved. In this article, we will discuss the key aspects of medical claims processing services and how they are transforming healthcare management.
Healthcare providers submit documentation of treatment and costs to insurance companies or their administrators. This includes itemized bills, medical records, and diagnostic test results. The claims processor reviews this information to determine what expenses are covered by the patient's insurance plan. They verify eligibility, check for prior authorizations if necessary, and examine charges to see if they adhere to usual and customary rates.
Any covered costs are then paid out either to the provider or patient. Meanwhile, uncovered expenses or those exceeding plan limits are tallied to calculate the patient's responsibility. All transaction details like allowed amounts, payment amounts, and patient balances are recorded and tracked. Periodic reports may be generated for providers, insurers, and other interested parties.
Services Provided by Medical Claims Processing Companies
Medical claims processing companies contract with insurance providers to take on responsibilities like eligibility checks, coding validation, payment determination, and disbursement. Their core functions can include:
– Claims receipt and entry – Scanning or manually entering claims data for processing in claims management software.
– Eligibility verification – Checking member databases to confirm patients have active coverage on dates of service.
– Benefits investigation – Researching covered services, exclusions, deductibles met, and outstanding balances in health plans.
– Coding validation – Reviewing procedure and diagnosis codes billed against industry standards and medical necessity guidelines.
– Payment calculation – Determining allowed charges, deductible/coinsurance amounts owed by patients versus insurers.
– Payment issuance – Cutting checks or doing EFT/credit card payments to providers for approved claim amounts.
– Denial management – Issuing rejection letters and managing appeals when payments are declined.
– Accounts receivable monitoring – Tracking provider balances, following up on unpaid claims, and performing collections.
– Analytics and reporting – Providing metrics on trends, top procedures, high utilizers, fraud/waste/abuse patterns, and more.
Benefits of Outsourcing Medical Claims
There are several advantages for health insurers, providers, and employers to utilize experienced third parties for medical claims handling rather than maintaining internal staff:
Cost savings – These firms benefit from economies of scale through centralized operations across many clients. Their overhead is lower per claim processed compared to keeping the function in-house.
Focus on core business – Insurance companies don't need to devote resources to hiring, training, and managing claims department staff. Providers gain back time spent on non-clinical tasks.
Reduced turnaround times – Automated claims management systems streamline workflows to curb lengthy reimbursement cycles for providers.
Regulatory expertise – Strict compliance is achieved through firms' specialized knowledge of different public/private plan requirements and coding rules.
Risk mitigation – Extensive auditing and data security measures help catch fraud and ensure personal health information is properly safeguarded.
Advanced analytics – Sophisticated reporting aids utilization review, cost containment initiatives, and service benchmarks that are hard to match internally.
On-demand scalability – Volume fluctuations are handled flexibly through staffing adjustments rather than maintaining standing staff that may sit idle at times.
Key Considerations in Choosing a Medical Claims Processing Vendor
With numerous options available, healthcare payers should thoroughly vet potential partner firms based on several key criteria:
– Experience level in the industry as well as with specific public/private plans and provider specialties. Look for 10+ years serving similar clients.
– Certifications and quality metrics like accuracy percentages, processing turnaround goals consistently achieved, and low appeals/denials. Ask for benchmark data.
– Breadth and configurability of the core claims management system to comply with diverse plan designs. Request demos of capabilities.
– Auditing and oversight processes to validate provider credentialing, coding rules followed, and payment calculations are accurate. Request audit reports.
– Training and account management services to help onboard new plan types, educate staff on policy/rule changes, and maintain service quality.
– Technology infrastructure robustness including multiple backup/recovery sites, frequent system updates, and security measures for protected data.
– Pricing model transparency into per-claim rates, additional fees, pricing commitments over time, and total estimated annual costs. Get cost comparisons with competitors.
Conclusion
In summary, delegating medical claims processing services to knowledgeable third-party administrators benefits both healthcare insurers and providers by reducing costs, speeding reimbursements, unburdening staff, and gaining specialized expertise to deliver compliant, accurate, and rapid financial transactions. But it requires due diligence to find a vendor that is experienced, high-performing, robustly resourced, and a good long-term value partner.
