MEDICAL CLAIMS PROCESSING

Many medical billing service providers and internal medical billing staff focus on getting the charges sent to the carriers and posting payments.  While these two tasks are paramount to getting paid on a timely basis and updates patient accounts it only represents 30-40% of the effort when providing full-cycle medical billing services.

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The least favorite and most neglected part of medical billing is Accounts Receivable management.  Most carriers who accept X12 837 ANSI transactions (electronic billing) will reject claims that have omitted or invalid information or when there are provider enrollment issues at the carrier.  Our medical billing teams review rejected claims 1 to 2 business days after claim submission to ensure these are resolved on a timely basis.

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We also analyze and perform variable statistics on dozens of ANSI denial reason and EOB remark codes.  These codes are provided by carriers which help us identify claim denial trends by practice, provider and insurance company to assess pervasive denial patterns. Oddly enough, approximately 30% of our medical billing denials are related to patient eligibility.  These types of medical billing denials could have been avoided if the medical practice personnel would verify patient eligibility prior to or during the patient visit.

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The other types of medical billing denial reasons we encounter are related to the following groupings:
 

• Coding errors

• Coding errors specifically related to bundling

• Claim requires additional information or documents to prove medical necessity

• Preauthorization not on file with carrier

• Medical necessity

• If the medical biller is not familiar with a medical specialty then a claim can be billed not in accordance with carrier specific guidelines

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The last bucket of Accounts Receivable inventory that need active follow-up are claims that are past due.  These are claims that were or appear to have been successfully transmitted to the carrier but there has been no response for a period of time. Medical billing relies on a few organizations to cooperate to ensure claims are received by the carriers.  For example, all medical billing applications rely on an organization called a clearinghouse who ultimately is responsible to complete the medical billing claims transmission to the carriers.  From time to time there are communication errors where the claim didn’t arrive at the carrier.

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Every medical practice should take the time to understand what your internal or external medical biller is doing to ensure claims are getting submitted timely and steps taken to follow-up on unpaid claims. 

 

If you need help with Accounts Receivable Management, contact us to find out how we may help.

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