How to improve your medical claims processing

Healthcare professionals spend an agonizing amount of time processing claims documentation. Automating your medical claims processing can save you time so you can focus more on patient care.


How to develop a successful digital transformation

Your enterprise can’t afford to disregard, put off, or abandon the very idea of digital transformation. It’s vital to gaining and/or maintaining your competitive advantage. Established and up-and-coming talent needs the right digital tools to thrive in – and when they thrive, your organization thrives. And, above all else, your customers expect it of you during every stage of their journey with your company.

Medical claims processing

Document processing is an area of business that can range from simple to complex. Some businesses may only have to verify a few invoices and pay them. Other organizations may have to send the documents they receive through a laborious, complicated process. With the risk of fraud always present, many businesses choose to add extra steps to their document processing tasks to ensure the documents are valid. In the field of health insurance, these extra steps are a necessary protective measure for medical claims.

Medical claims are bills that hospitals and healthcare providers send to the insurance company listed for the patient. These claims outline the exact services that were rendered to the patient so that the insurance company can verify the claim. When it comes to validating and approving payment for these medical claims, the document must first pass through several verification steps. Medical claims processing is one version of document processing, and its tasks can be even more complex than traditional business-to-business invoice processing.

In medical claims processing, the form that is used for a medical claim can be very important. A Cigna medical claim form is one that was designed to be sent to the Cigna insurance company. It is the form used by Cigna for medical claims processing and should not be used to send claims to other insurance providers. An HCFA claim form is one that was originally designed to be used for Medicare and Medicaid claims but has become a common form to send to private insurance providers. As with Cigna, the medical claim form Aetna uses is designed just for claims that are sent to Aetna. All of these medical claim forms are different but contain much of the same basic information. 

Medical claims processing can vary depending on these 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 companies

For healthcare providers and health insurance companies, medical claims processing can be a tedious list of tasks. This is why many choose to outsource and hire medical claims processing companies to do the work for them. These companies act as a go-between for the healthcare provider and the insurance company. The largest claims management companies work for hospitals and will take on every aspect of claims processing tasks. Dental claims processing companies are specialized versions of generic companies and they cover the unique tasks of dental claims processing.

Management of claims is a common task to outsource, and the top claims management companies provide services that make it easy for healthcare providers and insurance companies to remedy financial losses. It is easy to find a claims management company’s list online, but make sure to verify the company before making a decision. Since outsourcing is a risky endeavor no matter what the reputation of a company is like, it might be a better choice to keep medical claims processing in-house. One way to speed up medical claims processing tasks is to utilize a data capture software that can organize, validate, and capture data from claims forms. With Rossum’s Intelligent Document Processing software, healthcare providers and insurance companies can process medical claims without the manual hassle.

Medical claims examples

Before deciding to process medical claims in-house, it is a good idea to ensure that the medical claims processing team knows exactly what they are dealing with. Medical claims examples are a good place to start. By looking at an example of a medical claim, you can easily see what kind of information is commonly required and how the claim is organized. Now, you may be wondering, “Is a medical claim a bill?” The answer is yes and no. A medical claim is a bill in the sense that it is a document sent to the 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 it contains more information than just listing the money owed.

Another important piece of information to know before getting into medical claims processing is the definition of medical claims data. 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. This term usually references a large quantity of data from a group of forms for many patients and is used to compare and evaluate services and care provided by healthcare providers. Rossum can make it easy to gather data from medical claims forms.

Healthcare claims processing steps

Healthcare claims processing steps can 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 method of claims processing. It is also important to know the difference between medical claims vs hospital claims. Medical claims are bills from a doctor or individual healthcare provider requesting payment for services rendered to a patient. Hospital claims, on the other hand, are bills from a hospital or institution requesting payment for services rendered to a patient. 

A basic healthcare claims processing workflow follows these 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 make sure that the patient has an active plan. Verifying if the healthcare provider is in the network of the insurance company is the next important step. The insurance provider must also check that the patient was covered for the services they received.

One of the most important steps in verification is that the insurance provider verifies the medical treatment, specifically. Wrapping up the steps, the insurance company evaluates the claim risk and issues payment. With data capture being fundamental to all of these steps, Rossum’s software can automate that process so that medical claims processing becomes an easy task.

What is claims processing?

One vital question for healthcare providers and health insurance companies is: What is claims processing? At its root, claims processing is a description of the entire process for healthcare providers to receive payment from a patient’s insurance company for services rendered. When referring to what is claim processing in healthcare, the answer is that it is the beginning of the process. It is the healthcare provider that initiates medical claims processing by filling out the correct form and sending it to the insurance company.

A medical claims processor is a vital part of the claims processing workflow. This person is responsible for verifying all the data on the medical claim form, including the complex medical billing and coding data. This is a tedious job, however, but there are ways to improve the process. A claims processing software is a way to automate portions of the claims processing department and speed up the entire receipt-to-payment process. Software that utilizes Artificial Intelligence can do all the basic tasks and make more complex verification tasks easier. 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.

Medical claim form

At the heart of medical claims processing is the medical claim form. The information that most medical claim forms include 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 medical claim forms is the medical claim form 1500. This form was designed by the Centers for Medicare & Medicaid Services and contains some basic patient information as well as 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. Then there are portions of the form 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 the claim and ensure that there is no fraud. A medical claim status form is another form type that the healthcare provider would use. This form is sent by the healthcare provider to the insurance company to find out what the status of the claim is. Both of these forms contain a vast amount of very important information that needs to be captured and verified for medical claims processing. Rossum’s software can make this data capture an easy and efficient process.

Insurance claim processing services

Insurance claim processing services are available to health insurance companies that are interested in outsourcing some of the insurance claims processing tasks. Essentially, these services would replace an in-house insurance claims processor and take on the task of handling medical claims forms. These service providers can also verify 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. One type of claim processing service that would make medical claims processing more efficient is Intelligent Document Processing software.

An AI-powered Document Processing software can organize claims, fix basic errors, capture data, validate claims with human verification for assurance, and process the claims in one secure platform. A software like Rossum can be a helpful tool for health insurance companies that need to speed up their insurance claim processing tasks and issue payments reliably. Insurance claim processing requires a great deal of validation, but instead of doing this manually, Rossum can easily match the policy holder’s information with the medical claim so that validation is quick and efficient.

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