How to improve your medical claims processing

Medical claims processing

Document processing can range from simple to complex depending on your enterprise needs. Some businesses may have to simply verify a few invoices and pay them accordingly. Other organizations, meanwhile, continue to rely on laborious and complicated documentation processes. 

Many of these businesses choose to add extra verification steps to their document processing tasks to ensure documents are valid. In the field of health insurance, implementing these security steps are a necessary, protective measure to prevent fraudulent medical claims.

After administering treatment, medical claims are bills that hospitals and healthcare providers send to a patient’s listed insurance company. These claims outline the exact services that were rendered to the patient so that the insurance company can properly verify the claim. 

When it comes to validating and approving payment for medical claims, any submitted documentation must first pass through several verification steps. Medical claims processing is a particular kind of document processing that often involves even more complexities than traditional business-to-business invoice processing.

Medical Forms Section

In medical claims processing, the actual form that is used for a medical claim matters. A Cigna medical claim form, for example, is a form that is specifically designed to be sent to the Cigna insurance company. 

In this example, this form is the official form used by Cigna for medical claims processing and should therefore not be used to send claims to other insurance providers. Similarly, the medical claim form Aetna uses is designed just for claims that are sent to Aetna.

You may also come across an HCFA claim form at some point. Originally designed to be used for Medicare and Medicaid claims, an HCFA claim form is now a form that gets commonly sent to private insurance providers. Bottom-line? All of these medical claim forms are different—even if they contain much of the same basic information. 

Medical claims processing can vary depending on each providers’ forms, but the basic steps of validation, organization, data capture, data entry, and more are the same. Rossum’s Intelligent Document Processing software can help insurance companies process medical claims quickly and reliably.

Medical claims processing providers

For healthcare providers and health insurance companies, medical claims processing can amount to a tedious stream of tasks. Worse yet, these administrative tasks surrounding medical claims processing, when performed manually, place a significant burden on a company’s available resources and manpower. 

This is why many businesses wisely choose to outsource this busy work and hire devoted medical claims processing companies to do the work for them. These specialized medical claims processing companies act as a go-between for the healthcare provider and the insurance company. 

The largest claims management companies work for hospitals and assume responsibility for every aspect of claims processing—taking on processing tasks that were once carried out manually by hospital employees. Dental claims processing companies, for example, are specialized versions of generic claims management companies that cover the unique tasks of dental claims processing.

Overall claims management is a common task to outsource because the top claims management companies offer cost-effective solutions that make it easy for healthcare providers and insurance companies to remedy financial losses. 

While you can easily find a list of the best claims management companies online, be sure to verify each company before making a decision. Outsourcing can be a risky strategy no matter how sterling a company’s reputation might be—which is why some companies ultimately opt to keep medical claims processing in-house. 

Companies that decline to outsource speed up medical claims processing tasks by leveraging powerful data capture software that organizes, validates, and captures data from claims forms. 

With Rossum’s Intelligent Document Processing software, healthcare providers and insurance companies save time and money—automatically processing medical claims in a matter of minutes without stress.

Medical claims examples

Before deciding to process medical claims in-house, it’s a good idea to make sure your medical claims processing team knows exactly what they are dealing with. 

Your back office team should be familiar with a variety of common medical claims examples before taking on added processing duties. By looking at an example of a medical claim, you can start to quickly see how claims are organized, as well as the kind of commonly required information. 

Now, you may be wondering, “Is a medical claim a bill?” The answer is yes and no. 

A medical claim can be classified as a bill because it’s the document that gets sent to the given insurance company requesting payment for services rendered to the insured patient. 

On the other hand, a medical claim is not exactly the same as a bill because a medical claim contains more extensive billing information than just listing the money owed.

Before you dive into medical claims processing, it’s also wise to solidify your understanding of medical claims data and clear up any misconceptions surrounding its definition or use. 

Medical claims data includes all of the information that is listed on medical claims forms, including services rendered to patients, costs, insurance information, and more. Medical claims data is an industry term that usually references a large quantity of data—medical claims data can be sourced from a group of forms for many patients, and can be used to compare and evaluate competing services offered by healthcare providers. 

The good news? Rossum’s solutions make it easy to gather data from medical claims forms.

Healthcare claims processing steps: What you should know

Healthcare claims processing steps will vary depending on the rules of the healthcare provider and the destination of the claim. Looking at a health insurance claims process flow diagram is a helpful way to understand the most common methods of claims processing. 

The difference(s) between medical and hospital claims is another key distinction to understand before you’re ready to carry out subsequent processing steps with confidence. 

Medical claims are bills from a doctor or individual healthcare provider requesting payment for services rendered to a patient. Hospital claims, meanwhile, are bills from a hospital or institution requesting payment for services rendered to a patient. 

A basic healthcare claims processing workflow follows a series of basic steps. The first step is to review the claim and ensure there are no basic errors like duplicate charges or incorrect dates. 

Then, the insurance company must verify the insurance plan and that the patient holds an active plan in place with the insurer. 

Verifying if the healthcare provider at hand is in the insurance company’s in-network providers is the next important step. 

The insurance provider must also check that the patient is qualified and covered for the services they received.

Last, but certainly not least, one of the most important steps in the verification process occurs when the insurance provider specifically verifies the administered medical treatment. The insurance company in this scenario evaluates the claim risk and issues payment for accepted claims. 

With data capture being fundamental to all of the steps involved with medical claims processing, it’s no wonder health care providers nationwide rely on Rossum’s software to automate and streamline processing.

What is claims processing?

One vital question for healthcare providers and health insurance companies is simple: What is claims processing? 

At its root, claims processing describes the entire process that entails healthcare providers receiving payment from a patient’s insurance company for rendered services. 

When referring to the question of what is claim processing in healthcare, specifically, the truthful answer can often be the beginning of a more drawn out process. It is the healthcare provider, after all, that initiates medical claims processing by filling out the correct form and sending it to the insurance company.

Given these responsibilities, a medical claims processor becomes a vital part of the claims processing workflow for insurers and healthcare providers, alike. Without a full time medical claims processor, companies often struggle to verify all the data on medical claim forms, including complex medical billing and coding data. 

Yet even with a processor in place, these verification duties can unsurprisingly amount to a tedious, not to mention, time consuming job. 

The good news is there are ways to upgrade and streamline the process. Companies use claims processing software to automate portions, if not all, of their claims processing department and speed up the entire receipt-to-payment process. 

Software that uses artificial intelligence performs all of the basic processing tasks with precision while simplifying more complex verification tasks. 

Rossum’s AI-powered Document Processing software can handle the initial validation, data capture, verification, and organization of medical claims forms so that the medical claims processor can focus on verifying the important data.

Addressing the complexity of medical claim form processing

Remember: at the heart of medical claims processing is the medical claim form. The information that most medical claim forms contain is used by the healthcare provider to describe the services they performed for the patient and by the insurance provider for verification before issuing payment. 

One of the most common forms is the medical claim form 1500. This form was designed by the Centers for Medicare & Medicaid Services and includes basic patient information as well as some of a patient’s more specific medical data. 

The 1500 form contains the patient’s name, address, and birth date, as well as the insured’s I.D. number, name, address, and relationship to the patient. There are additional sections within the form marked for signatures and claim-specific information, such as the date and place of service and the procedure itself as well as the provider’s I.D. number. All of this information is used to verify valid claims and prevent fraudulent ones. 

In addition, a medical claim status form is another common form type that a healthcare provider will often use. The healthcare provider sends a medical claim status form to the insurance company to find out what the status of the claim is at any time. 

Both forms contain a vast amount of critical information that needs to be accurately captured and safely verified for medical claims processing. Rossum’s powerful claims software transforms this data capture into an easy and efficient process.

The best insurance claim processing services

Insurance claim processing services are available to health insurance companies interested in outsourcing time-consuming processing tasks. These automated services can replace your in-house insurance claims processor and assume the task of handling medical claims forms. 

These service providers are also effective at verifying claims for the company so that the insurance provider can focus on issuing payments. Insurance claim processing services are readily available, but may not be a secure option. 

Instead, there are other insurance claim processing services that might be more affordable and secure than choosing to outsource. A popular claim processing solution that helps optimize medical claims processing is Intelligent Document Processing software.

An AI-powered Document Processing software can organize claims, fix basic errors, capture real-time data, validate claims with human verification for assurance, and process claims—all within one secure platform. 

Rossum’s advanced, enterprise-grade software helps health insurance companies speed up their insurance claim processing tasks and issue payments reliably. Insurance claim processing requires a great deal of validation and security. 

Instead of performing these tasks manually, Rossum can easily match the policyholder’s information with the medical claim so that the validation process is quick, efficient, and precise.