Potential Billing Problems And Returned Claims In Healthcare

The practitioner’s foremost duty is to provide extraordinary patient care, which is a primary reason healthcare providers join the medical field. While becoming specialized doctors and experienced practitioners, they spend time and money to achieve this goal. Now they can be empowered to be paid fairly for their services. People cannot even imagine the cost of running a medical practice -the building, staff, insurance, technology, and much more. It means practitioners have to be vigilant about their medical billing procedures.

The medical claims billing department is the primary key to the profitability of any medical practice. Bills must be generated on a timely basis, submitted accurately to several insurance companies and government institutions, and subjected to regular follow-ups to ensure prompt payments are received. A solid medical claim billing service leads to good cash flow and improved revenue cycle management.

The claim billing process in medicine is invoices that practitioners send to the insurance companies after patients receive care. It details the patients’ services and the charges associated with the services adjusted by the doctors or the facilitator. These services can be communicated by a standardized medical code called Current Procedural Terminology (CPT).

Denied And Rejected Claims

Rejected claims are the result of an error found in the initial submission. They are returned to the biller for correction and then resubmitted for payment.

Rejected claims are a common occurrence in healthcare billing, especially when dealing with insurance companies. Rejected claims are not the same as denied claims. A denied claim is one that has been processed once by the insurance company and has been determined by them not to be valid. In other words, they will not pay for it.

These claims contain one or many errors found before the claim is processed. These errors prevent the insurance company from paying the bill as it is composed, and the rejected claim is returned to the biller in order to be corrected.

A denied claim occurs when an insurance company denies coverage for a particular service provided by your facility, usually due to a lack of medical necessity or non-compliance with network rules on their side.

Reasons that Claims Could Be Returned By the Insurance Companies

When an insurance company denies a claim, it doesn’t mean that they don’t want to pay your bill. It means that they don’t think they should have to pay for it. The reasons for denial can include billing errors, missing information, inadequate patient coverage, and more. Your practice will typically receive an Explanation of Benefits (EOBs) with the reason for the denial.

You may be able to correct some of these denials or get paid for them in full. But if not, you can appeal to them and reprocess them in certain cases.

Missing Information

A claim can be denied if an important piece of information is missing from the claim submission. For example, if you did not include a diagnosis code on the claim form, it will likely be denied by the insurance company due to a lack of information. Make sure that all required information is included on all forms before submitting them so that they cannot be rejected due to lack of information.

Denied claims may be appealed and reprocessed in certain cases

Insurance companies say a denied claim is unpayable; however, denied claims may be corrected and resubmitted for processing with the insurance company if you can provide additional information or documentation to support your claim submission

How submitted the Medical Billing Claims 

Medical claim billing is a complex process involving 20+ checkpoints through which every claim must pass before it’s approved. If a claim passes through all these checkpoints without restrictions, the insurance companies support and proceed with the insurance payments. If the claims cannot make it through these checkpoints, they get rejected and denied.

The claims submission process in medical billing follows a proper system, Some common straight steps are given below :

• Claims enter the system:

Often, weeks after the appointment, the clearing house receives mail from the doctor’s billing department. Here it goes for data entry. Data entry can be entered through electronic devices.

• Review the data initially:

The data is run through an algorithm to ensure it does not contain duplicate charges, typo errors, inaccurate data, or illegible content. It also makes sure doctors file the claim within the deadline.

• Eligibility check:

In the healthcare claims billing process, check the name and policy number to verify that the client is an active member of an insurance plan.

• Network:

 The system checks a practitioner or clinic location against the database to verify that it is in the same network.

• Apply negotiated pricing:

The insurance company and the healthcare facilitator signed an agreement after negotiating rates for medical claim billing.

• Check member’s benefits:

Here, insurance companies give detailed information about the benefits they are covering. How much do they pay for each service provided by the practitioner?

• Review medical necessities:

In this step, they make sure services provided by the healthcare provider are needed.

• Payment and bill:

Now, insurance companies send payments to healthcare providers based on negotiated rates. The medical biller checks its EOB(explanation of Benefit) to ensure the information is correct and matches the services.

This is a process of how medical claim billers perform their duty and keep their sight on all the steps involved in the medical billing process, but they also try to reduce errors and denials.

To learn more about the claim submission process in medical billing please visit here