Healthcare Claims Processing Workflow: Tools and Processes to Increase Efficiency

If we’re going to talk about how to improve efficiency within healthcare claims processing, we should start at the very beginning. The journey of a claim from the time a patient has an appointment, to the time the bill is paid, is a lengthy one. 

There are at least a dozen steps that a piece of data must go through to get the bill to the payer accurately. Some processes used currently are still a little outdated such as paper medical records, however, there are ways to ensure accuracy while also improving efficiency during this complex workflow.

Let’s simplify the steps.

• A patient is seen at a clinic or with a provider. That appointment and those services are coded and submitted electronically or via paper and mail.
• Once the paper claims are received, they are scanned or manually entered. Electronic claims will enter the system directly.
• Initial review. Check for spelling, dates, duplicate charges, etc.
• Locate a patient in the system and ensure they had insurance coverage at the time of service.
• In-network review. Check to make sure the doctor and/or facility are in-network based on the patient’s insurance plan.
• Negotiate pricing. What does the doctor get paid? What will go on to the insurance provider? What part will the patient themselves pay?
• Check the patient’s benefits. What is covered and what is not?
• Confirm medical necessity. Medically necessary procedures are essential to note, to determine eligibility for insurance coverage in most cases.
• Evaluate claim risk, a.k.a. quality assurance. Are there any abnormally high charges? Any signs of fraud?
• The provider/doctor gets paid.
• An explanation of benefits (EOB) is sent out to the member. This is not a bill but shows what was or wasn’t covered, and what they can expect on their bill.
• The member is billed for the remaining balance of what insurance didn’t cover.

As you can see, even with electronic records, there are several steps that a claim goes through before it reaches its final destination. So how can businesses improve efficiency and quality in such a complicated process? We have a few suggestions.

Streamlining the Healthcare Claims Processing Workflow

There are a few ways to streamline the claims process within your company. Consolidation, outsourcing, and advancements in AI can all help alleviate some of the gummed up processes of claims management. Streamlining processes can help to avoid any hold-ups of the insurance claims process in your facility.

Consolidating Workflows or Departments

As we displayed above, you can see all the different steps a claim goes through to reach its final destination. Processing claims can be lengthy if things aren’t well-organized, and the steps make sense. Within your facility, a claim should be limited to how many hand-offs take place.

Although HIPAA has regulations and rule sets on how claims should be processed electronically, there are still some manual processes involved. And the more hands a claim goes through, the more risk for error. That’s where outsourcing comes in.

Outsourcing Claims Management Services

Hiring a BPO agency to take care of your claims management services can be highly beneficial when it comes to processing medical claims for your members. Smart Data Solutions’ claims management services take care of everything from the health insurance correspondence to provider and member matching and quality control.

Outsourcing claims management can free up time and space for other tasks within your facility. It can also save you money as well as help you avoid issues like turnover and training. Outsourced teams can also take the pain out of the negotiation processes. Having a representative looking out for both your providers and members can make all the difference.

Improving Information Technology Systems

Automation is the key to improving efficiency and accuracy, especially in the healthcare industry. Advancements in OCR (optical character recognition) alleviates the struggle of having to use different templates for different forms. It can automatically match providers and members just by a few specific data points like name and DOB. Machine learning and AI partner together to ensure no data is missed, everything is accurate, and errors are caught before they get to the medical billing stage.

According to HIPAA, the two most common claims submission forms are the UB-04 and CMS-1500. The main difference is that UB-04 forms are used in facilities like hospitals and larger institutions whereas the CMS-1500 forms would come from a smaller facility like private practices. With the help of machine learning and AI you can automate these form variations by putting templates and automated processing in place so the same process can be done no matter what form is being scanned or input. AI can take the proper fields from the form and match it up into a standardized format that helps to avoid any errors or misinformation.

How Auto-Adjudication Can Improve Claims Efficiency

Finally, adjudicated claims can improve the customer experience overall by being processed faster, more accurately. To adjudicate claims, in short, means to automate how the responsibility of the payer is determined. When a claim reaches them, it will be paid in full, denied, or the price will be negotiated based on the member’s health insurance coverage. You can read more about auto-adjudication here.

By implementing auto-adjudication within the claims processing workflow, payers, providers, and members can see an influx of faster and more accurately processed claims. Members’ claims will be processed faster, the healthcare provider will get paid faster, and the insurance company can have fewer pending claims outstanding.

 If you’re finding yourself in a situation where your healthcare claims process is overwhelming, inefficient, or you’re finding errors and gaps, give us a call! Smart Data Solutions can offer services from automating how claim forms are read in your system to processing your members’ medical insurance with a claim. We are here to help your facility become as efficient as possible. Contact us here.