If medical claims management is such a vital part of the healthcare ecosystem, why is it so frustrating? The answer often boils down to a process riddled with administrative burdens, a complex coding system, and predisposed to errors due to outdated technology and frequent rule changes. 

With this in mind, it’s no wonder that efficiency and accuracy in the claims management process are not just goals—they’re vital for a practice’s longevity and financial health.  

In this article, we’ll dig into this complex process to discover the top claims management challenges and reveal the costs to practices. Don’t worry; we’ll also recommend actionable strategies for quick wins and long-term solutions, improving medical claims processing for better results and happier staff. 

Challenges of Healthcare Claims Processing 

A medical claim is a request made by a healthcare provider to insurance companies (payer) to receive reimbursement for services rendered. It’s also a big part of accounts receivable. Typically, a claim includes: 

• Patient registration 
• Prior authorization  
• Charge entry  
• Medical coding 
• Claim submission 

Once the provider submits a claim to the payer, they review the claim to determine whether it meets reimbursement requirements or adjudication. If the claim is approved, the payer pays the provider for services rendered.  

Easy, right? Not if you ask billing managers. The truth is that the road conventional health insurance follows in processing claims is needlessly complicated, leaving room for many unwanted errors and frustrated providers. What are the main reasons behind these issues? Take a look at the top three below. 

1. Data capture: Manual data entry in the claims process is prone to errors and missing information, resulting in denials. One report reveals that the increase in claim denials primarily results from inaccurate data. 

2. Prior authorization: The American Medical Association (AMA) found that 88% of physicians described the burden of prior authorization as high or extremely high. 

3. High denial rates: The growing rate of claim denials is a major threat to healthcare revenue cycle management (RCM). One survey revealed that 15% of medical claims submitted to private payers for reimbursement are initially denied.  

The Cost to Providers 

Now that we understand the main reasons behind claim denials and complicated RCM processes – what’s the cost to you – the provider?  

• Financial costs. Researchers found that claim denials can cost providers around $500,000 in annual revenue. 
• Lost time. One report states that practices complete 45 prior authorizations per physician weekly and dedicate almost two business days each week to the process. 
• Patient frustration. Patient satisfaction may be at risk. A survey found that patients who experienced a claim denial rated their satisfaction with care 8.2 points lower than those who didn’t. 

Now, the positive news. Healthcare providers and organizations have the power to improve medical billing and collections. Below, we offer effective strategies rooted in advanced technology and solutions that promise to transform the claims management process. 

Claims Management Process Strategies for Acceptance Success 

What does optimal RCM look like? It hinges on streamlined healthcare operations, including how your medical practice handles insurance claims.  

By optimizing the medical billing workflow and integrating claims management tools and solutions, you can minimize denials, reduce processing times, and ultimately improve patient satisfaction.  Here’s how: 

Automate, Automate, Automate

Many practices lack billing systems that automate operations and identify potential problems before they happen. Switching from a manual to an automated claims submission process that uses advanced technology, like AI intelligence for billing, allows providers to: 

• Eliminate common front-end data entry errors, like capturing patient information, ensuring accurate claim submissions.  
• Engage in real-time tracking, giving immediate insights into the status of each claim. 
• Process a bulk submission of claims, significantly speeding up the process and improving revenue cycles. 
• Conduct deep data analysis. Helping providers glean insights into cash flow.  

Make Payment Easy

What are other steps you can take to improve claims management? Make your payment processes and options easier for patients. Here are practice management solutions that will greatly enhance your revenue lifecycle:  

• Investing in a tool that quickly generates patient estimates before or during service improves collections and provides transparency that patients trust.  
• Provide a secure online platform for patients to make payments, view bills, and update insurance information. 
• Using features like in-app credit card processing helps providers collect more co-pays, deductibles, and co-insurance deductibles.  

Upgrade Your Software

Having the right claims management software ensures your staff can see the complete revenue cycle in real-time and enables an effective workflow.  

For example, cloud-based practice management software CollaborateMD simplifies billing and provides transparent reporting tools to streamline your claims process. Solutions include: 

• Charge capture. An integrated app for seamlessly managing patient notes, billing codes, and rounding lists. Eliminates lost or missed charges.  
• Electronic claim submission. Allows providers to know if claims have been accepted quickly. The feature can also identify and correct rejected claims to receive accurate insurance payments.  
• Real-time patient eligibility. Find out if a patient is eligible in seconds. 
• Claims scrubbing. Reduce claim rejections with built-in billing and coding edits. Allows for accurate reimbursement and faster payments.  

Prioritize Denied Claims

Claims denial management should be a priority in your practice. Establish a dedicated team or use claims management software to pinpoint and analyze denial trends and develop strategies to address recurring issues. Getting ahead of the problem quickly can improve claim acceptance rates, resulting in faster payments. 

Adopt Best Practices  

Adhering to claims processing best practices is essential for maintaining efficiency. This includes regularly training staff in coding and billing procedures, keeping up to date with the latest industry and HIPAA regulations, and conducting routine audits to identify areas for improvement. A well-trained team is your first line of defense against preventable errors. 

Final Thoughts 

Streamlining your medical claims management process is not a one-time task but an ongoing practice of refinement and innovation. By focusing on automation, leveraging data analytics, prioritizing denied claims, and implementing best practices, healthcare providers can enhance their RCM, reduce administrative burdens, and improve patient satisfaction.  

Ready to take your revenue lifecycle to the next level? Explore our range of advanced claims management solutions designed to meet your unique needs.