Medical claims management is the process by which insurance payer companies assess claims and determine their validity and the extent of coverage. Software for medical claims improves the speed and efficiency of the entire process of claims management in healthcare. This is possible through automation. Automating all the repetitive and manual tasks increases the overall speed of healthcare claim processing and decreases mistakes. In other words, increased speed and reduced mistakes ultimately result in greater productivity. As a result, fewer, if any, fraudulent claims are getting approved.
An insurance company would deal with dozens or even hundreds of claims each day. In light of this, some are bound to be fraudulent but still get approved. Estimates show that insurers lose several million dollars to such claims. However, the claim management software that OSP can build will improve the efficiency and accuracy of the claims assessment process. As a result, it will become easier for payers to detect suspicious claims and reject them.
Software for healthcare claim processing accelerates and optimizes the entire process of claims management significantly. This means that payers can assess a higher number of claims each day without any increase in their staff strength. In other words, claims processing software enables them to do more with less. By increasing productivity without an increase in overhead, claim processing software ultimately results in higher payer revenues.
Due to several unforeseen factors, processing claims can take longer than expected. These delays can sometimes result in delayed treatments, leading to adverse consequences for patients and anxiety. But a claim management solution streamlines the process of analyzing claims, resulting in faster payment decisions. Needless to point out, patients can avoid the stress and anxiety of slow processing.
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Claims management in healthcare consists of all the procedures, processes, and protocols that insurance payers carry out in the claims workflow. It begins with receiving the claim from a provider and processing it to determine its validity. If found valid, the payer company approves it, or rejects it in case of problems. Management of claims is one of the central operations at insurance companies
The process of claims management involves the series of steps in which insurance companies verify claim requests for justification, validity, and authenticity. If everything is found to be proper, the
insurance company will reimburse the provider. If there are issues found in the claim, the insurer might withhold the payment partially or completely.
The process of claim management involves –
1. Claim Adjudication – This involves verifying everything about the claim to determine its authenticity, compliance, and the necessity of the medical services rendered by the physician.
2. Explanation of Benefits – Also called as remittance advice, it is the details of the insurance payer’s adjudication and contains the reasons for reimbursing or rejecting the claim.
3. Claims Settlement – This is where the payer settles the amount that is to be paid to the provider for medical services rendered.
The purpose of claims management is to enable insurance payers to streamline the entire process of adjudicating medical claims. The workflows surrounding claims adjudication accounts for a bulk of the time, resources, and overhead for payers, and optimizing it can speed up the entire process, improve its accuracy, and also minimize the chances of insurance fraud.
Research and studies estimate that health insurance fraud costs billions of dollars every year. In light of this, a set of protocols and processes aided by dedicated software platforms can streamline claims management and optimize the whole process. This reduces the time taken for reimbursements, helps patients receive the care they need, and benefits payers in terms of greater productivity and a reduction in overhead.
Claims management is a win-win for all stakeholders involved.
A claims processing software is a digital platform to carry out the workflows associated with claims management. It digitizes all the activities involved in adjudicating claims and in doing so, improves the speed, efficiency, and productivity of the whole operation. Additionally, a software platform for claims processing would also include automation, which would eliminate the need for repetitive procedures that don’t require conscious decision-making by a human. This greatly improves the speed of the claims processing, while also minimizing errors.
Medical claim management is the set of processes by which healthcare insurance companies assess medical claims to determine their validity and the extent of coverage to be provided. It forms the major part of day-to-day operations at insurance payer companies and is also key for providers’ revenue cycles. If the claims are found to be fully valid and complaint with policies, the payer would reimburse the
provider fully. In case of discrepancies, the amount of coverage could vary. In cases of significant problems, the claims are rejected
Medical claim processing
Insurance payer companies receive claims from medical providers for the services they render to patients. The claims contain details of the services, coupled with the patients’ demographic information. These claims are evaluated by dedicated professionals who assess each claim to check its validity. This process involves verifying if the services were covered in the health plan, the importance or necessity of the medical services, and other formalities in preparing the claim. This entire process can be termed as medical claim processing.
Medical billing is the process of sending healthcare claims to insurance payers for reimbursement for medical services offered. When a doctor provides medical services to a patient, the services are translated into standardized ICD codes to generate the claims. The claims are nothing but accurate summarizations of all the medical services rendered to the patient.
Medical claim processing automation is the process of automating processes and workflows associated with claims adjudication. Automation removes the need for human intervention in processes which are repetitive and don’t require conscious decision-making. In doing so, the staff involved in claim processing can focus on other important tasks and still get more work done, with few or no errors.
In short, automation in medical claim processing improves the speed, productivity, and efficiency of preparations, while lowering the overhead involved.
The following steps can improve the efficiency of medical claims management activities –
1. Refresh patient data
Patient data is subject to changes over the course of time. Factors like age, employment, recent medical treatments, and medications matter when it comes to claims adjudication. So, it is important to ensure that patients’ data is always up-to-date.
2. Optimize adjudication workflows
Efficiency of the adjudication process is vital for medical claims management. It is important to ensure that adjudication is done by experienced professionals and to have redundancy checks in
place. Using a dedicated software for automation is known to boost the speed and accuracy of this process significantly.
3. Have safeguards against fraudulent claims
Fraudulent claims cost billions of dollars to the healthcare insurance industry. It is necessary to have the best safeguards against those. The latest tools include artificial intelligence and machine learning-based platforms that can detect deviations against pre-established norms and flag suspicious claims for further verification.
Efficient claims management in healthcare is vital for all the stakeholders involved. It is necessary for the payers to assess claims and reimburse providers accordingly and also avoid over-paying. For providers, good claims management ensures healthy revenue cycles due to timely reimbursements. For patients, the waiting times for important medical procedures and treatments would decrease if payers can approve of the claims faster.
Automating the healthcare claims management process requires a dedicated software solution. Payers looking for automation need to approach companies that offer software automation, or business process automation solutions.
It is important to approach a vendor that has been in business for more than a few years and has a sizable clientele. Have a look at the vendor’s portfolio of products and services, in addition to visiting an insurance payer company that uses the vendor’s products.
After selecting a vendor, you can either opt for a custom-built solution, or a pre-built one. A custom solution will be made exactly according to your needs, while a pre-built one will have a general set of features common for claims management. The former is more expensive than the latter.
In case of custom solutions, experts from the vendor company would assess your business processes and claims management workflows. This will enable them to develop a framework for an automation software to suit your needs.