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Dealing With Credit Claim Denials: Strategies From Boston Attorneys – You submit a patient’s claim to their insurance, their payroll takes care of it, and they pay you. simple enough, right?
It’s true about the claim submission process, it’s definitely not easy. Any experienced medical biller will tell you that there is a lot involved in the three steps I just listed and the details that are most important in each step.
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Regardless of how one particular claim is denied, all of them go through the same process once received by a payee…judgment.
Insurance Claims Specialist Cover Letter
Although the claims adjudication process is not something your organization has complete control over, there are actions you can put in place to better ensure your chances of getting paid are better.
In short, a claim adjudication is a process that each insurance payer goes through to determine how much they owe a provider based on the claim they received.
The ideal scenario for the health care organization that submitted the request is that the payer decides to pay in full. When that happens, the health care organization will show a credit in your bank account for the full amount.
In some cases, the payer will decide that they will only pay a portion of their debt to the health care organization based on the claim. This scenario occurs when the payer finds that the service level priced is not appropriate based on encryption or procedural codes. It’s a frustrating situation when this happens, but at least there is SOME form of compensation.
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Currently, the worst case scenario is that the claim is denied as a result of the trial. Denial occurs when there are obvious errors in the submission. When a denial occurs, the payment is sent back to the health care organization that sent it with a reason for the denial. Unfortunately, payments do not compensate for denials until they are fixed and resubmitted (more on that later).
As with the Electronic Data Interchange (EDI) registration process, claim adjudication looks different for each payee.
The chart above comes from Oracle Health Insurance. This fundraiser has an entire website dedicated to explaining its legal work.
As you can tell from the chart, the process is pretty simple, right? I am rude. It’s great that Oracle Health Insurance took the time to create a flowchart that graphically explains its process for adjudicating a claim, but it’s certainly not easy to understand.
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Basically, the exception to this payment scheme is that you submit a claim and it runs a series of checks and balances against it based on the relevant scheme.
It’s a nice graphic, but it’s not very helpful. Let’s break down the steps most lenders take when making a decision.
The first step in the trial process is the preliminary due process review. Believe it or not, this is where many claims end up being denied.
In this first step, the payer checks the claim for errors or simple defects. In particular, money depends on the accuracy of…
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If a claim fails at this point, it will be sent back to the organization that submitted it. Of course, that means it gets a “denied” status. Denials aren’t the end of the world because you can resend them… but reworking and resending them costs company resources.
The automated review step takes a detailed look at whether the case is compatible with the paid policies. Specifically, this step seeks to determine whether or not…
The third step is when a trained, professional medical claims examiner steps in. In some cases, the investigator may bring in a nurse or doctor to look at the claim as well.
In addition, many payers agree that this is a necessary diet in the process. It is not unusual for a medical record request to be made at this point. Claims of that nature will not happen every time, usually only for unlisted procedures to determine medical necessity.
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The last two steps in the standardized adjudication process occur only after a case passes three stages of review. In other words, it is how health care organizations get money from payers.
Before we continue I have to confess something to you… in the legal process, receiving money from a payee is not “money”. The payment that results from the adjudication of claims is called a remittance advice or payment explanation.
Money Along with the payment or credit associated with the claim comes an explanation. These explanations provide details about the reasons for…
Of course, that’s easier said than done. In particular, these reasons include the following key data points…
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Of all the payment determination statuses a claim can receive in the payment adjudication process, “denial” is the most frustrating to deal with.
Do you remember when introducing this blog post when I said that 30% of all claims are denied? I wouldn’t have prefaced that statistic if it wasn’t one of the biggest pain points healthcare organizations deal with when they deal with payments.
You see, when a case doesn’t pass all the checks in the payment adjudication process, it is sent back to the organization that originally submitted it with a “denied” status.
Basically, a denied claim means that the insurance payer won’t pay you for the services you provided to a patient.
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In addition to not receiving payment, denials also require organizational resources to rework and resubmit the case as an appeal. Thus, accepting the appeal costs the organization more than the original submission.
The clear argument against it is that, “money is money”. But the better answer is that setting up real services for claim submission AND appeal reduces all operational costs.
In essence, clearinghouses take the burden off the shoulders of healthcare organizations and check all preventive claims before submission.
I’ve already mentioned this, but each payer has different EDI registration AND legal requirements. On top of all that, the majority of patients seeing health care organizations will all use different insurance payers.
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Previous sanitariums have contacted thousands of money (we have these). In other words, registration with proper clearance immediately takes those tedious tasks off the health care organization’s plate.
Part of their added value is claim clearing because clearinghouses know innately what the legal process needs look like for thousands of claimants because they deal with them.
Claim clearing is the process of submitting a claim to a clearing house BEFORE paying. When this happens, the clearinghouse compares the claim with the payment requirements and provides feedback on it.
Claim validation is available as a “spell check” function. The clearinghouse identifies errors before adjudicating payments so that the health care organization does not receive a denial.
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Obviously, many processes occur during case adjudication that are beyond the control of the presenting health care organization.
The only form of “check” that the health care organization has after they submit a request for a payment is to make sure it was 100% accurate BEFORE submission.
However, some clearinghouses (like ours) provide the ability for healthcare organizations to gain insight into the status of their claim submission.
Knowing the status of the claim makes it easier for the healthcare organization to predict its revenue sooner. If the organization checks the status of its submitted claim and it doesn’t look good, it can also initiate the appeals process.
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Of course, when it comes to dealing with insurance premiums, things are not as simple as they seem. Adjudicating the claims process is no different.
Fairness is an industry term used to describe the internal process that funds go through to determine whether or not they reimburse the organization that sent them.
It’s definitely up there as one of the most difficult revenue cycle processes… especially since so much of it is out of the control of the delivery organization.
However, partnering with a clearing house (such as ) facilitates adjudication by streamlining front-end processes and providing insight into the status of each submitted claim. Accurately capturing patient details is probably one of the most undervalued processes in the revenue process chain. . Not only does the data captured in the demographic entry process form the basis for the medical record, but it also affects the payment of insurance claims. Error-free capture of patient information is essential for clean claim submission and facilitates rapid processing of claims by Payers.
Life Insurance Denied
The front office at the facility must accurately capture patient information, either through paper-based registration processes or through a scheduling system. Accurate patient information is essential for determining patient rights and interests, obtaining prior authorization, and filing claims without error. Furthermore, population health analysis is only possible using accurate patient information.
At Medical Billing Wholesalers, we have trained our team of revenue cycle experts to validate all the information available on the forms. Our team contacts the provider’s office or the medical billing company if the information is incomplete or incorrect in the event of a discrepancy. Our team members enter certified data on the client’s practice management software at a high level
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