Medical Claims Processing Services: Streamlining Healthcare Reimbursements

Understanding the Medical Billing Process

For any medical practice, efficiently processing insurance claims and collecting payments is crucial for financial viability but can also be an administrative burden. The medical billing process typically involves verifying patient insurance eligibility, submitting claims to insurance providers, tracking claim status, resolving rejects or denials, processing payments, and billing patients for outstanding balances. For the average clinic, this cycle of insurance submission and payment collection can be time consuming and complex to manage internally given the numerous public and private payers involved as well as constantly changing coverage rules and regulations.

Outsourcing Medical Billing to Reduce Costs and Free up Resources

Many medical practices choose to outsource some or all aspects of their billing needs to specialized medical claims processing services companies. These firms employ technologies and dedicated staff to handle the paperwork and follow up required to get reimbursed for services rendered. By offloading billing administration, practices can focus resources on patient care activities rather than spending time on paperwork and phone calls with insurance companies. Outsourcing also allows clinics to take advantage of economies of scale since billing vendors process claims for many different provider clients simultaneously using standardized systems and workflows. This increased efficiency through specialization and centralized infrastructure can significantly reduce per-claim billing costs compared to an in-house model.

What Services do Medical Claims Processing Companies Offer?

Full-service medical billing companies provide an end-to-end solution by taking responsibility for all billing functions from the initial eligibility check through final payment collection. Common offerings include:

- Insurance verification and eligibility - Checking patient insurance details prior to treatment to confirm coverage status.

- Medical claim form preparation - Filling out standardized billing forms with appropriate diagnosis codes, procedure codes, and provider identifiers.

- Claims submission - Electronically submitting claims to both public (Medicare, Medicaid) and private payers on the provider's behalf.

- Payment posting - Receiving EOBs (explanation of benefits) and payments, depositing funds, and updating patient accounts accordingly.

- Denial and rejection management - Researching any unpaid claims, appealing as needed, and resubmitting to resolve unpaid statuses.

- Accounts receivable follow up - Sending patient statements and making collection calls or transferring unpaid balances to collection agencies as required.

- Reporting - Providing actionable reports on metrics like submission volumes, reimbursement rates, denials/rejections.

Selecting the Right Billing Service Provider

When selecting an outsourced billing vendor, practices should consider key factors like specialty experience, credentialing support, technology platforms, billing cost structures and transparency of reporting. Look for companies that have experience serving providers in your specific industry segment like primary care, specialist practices or ambulatory surgery centers. They should also be able to handle credentialing with insurance plans to facilitate network participation. Firms utilizing robust, integrated software platforms for claims transmission and tracking tend to achieve higher reimbursement ratios through efficiency and scalability. Understand any set up fees involved as well as ongoing service costs that may be charged on a contingency basis for collected amounts. Thorough reporting is also important for oversight of billing KPIs. Finding a partner focused exclusively on medical billing can ensure priorities are well-aligned.

Transitioning to Outsourced Billing

Switching to an outsourced setup requires adequate preparation to ensure a seamless hand-off. Key steps include:

- Inventory existing patient and insurance information to transfer relevant data fields.

- Review historical claims data to obtain performance benchmarks and audit transition quality.

- Coordinate credentialing submissions and approvals with the new billing vendor.

- Communicate changes to patients to facilitate direct payment of balances to the new servicer.

- Maintain access to billing systems during transition for ongoing oversight and reporting needs.

- Set regular check-ins to address questions, clarify responsibilities and refine processes.

With diligent planning and coordination, most practices can transition billing functions to an external partner within 60 days while maintaining cash flow. Outsourcing to experienced medical claims processing services processors delivers tangible benefits of cost savings, efficiency gains and reduced administrative burden - allowing practices to devote greater focus to patient care.