AquinaOctober 25, 2018

Improving Medical Claims Management In Your RCM

Improving Medical Claims Management In Your RCM

As part of our revenue cycle management (RCM) series, we’ve covered many aspects of its importance in healthcare, from information for beginners to deeper dives into front-end vs. back-end functions. However, what we haven’t examined directly is the centerpiece of RCM, and that’s medical claims management.

What are medical claims?

A medical claim is a request for payment that providers submit to insurers for related items and services that should be reimbursed based on the insurer’s contracts with the provider and covered patient. However, it’s rarely as simple as it sounds to ensure repayment actually happens.

What does the claims management process look like within the revenue cycle?

The claims process starts when a medical insurance policyholder (patient) sees their healthcare provider (physician or the like) for any range of reasons, from a simple consultation to a major surgery. Most insurance plans require a deductible be met. More and more commonly, though, high-deductible plans are the norm, which can mean patients are responsible for many hundreds or even tens of thousands of dollars in deductibles before their insurance will start paying.

Once a patient has been seen by a practitioner, medical billing and coding specialists take over. These are two of the most important functions in RCM because accuracy in these areas is what ultimately predicts whether or not a claim is reimbursed the first time around. Shockingly, as many as 80% of claims are submitted with some sort of error. When this happens, claims are usually denied, creating holes in the revenue cycle that can put practices at risk, especially if it happens frequently.

Meeting the challenges of claims management.

Once an insurer receives a coded medical claim, it can do one of three things:

  1. Accept and pay the claim in full.
  2. Deny the claim due to a billing error, which could be any of a range of reasons from incorrect coding to the inclusion of inaccurate patient information. When this happens, the bill is returned to the provider for correction and resubmission.
  3. Reject the claim completely. This happens when the services being billed on the claim are not covered by the patient’s health plan. When this occurs, the policyholder can challenge the claim, but ultimately, unless the rejection is overturned, will be responsible for paying for the service out of pocket.

Although providers have no control over number three, the first two are well within their ability to influence. Number one is the result of accurate medical coding and billing the first time around, and is of course, ideal. Number two is the result of the opposite, and it is why investing in thorough training for medical billing and coding professionals is important, especially when they do not have many years of experience behind them. The training pays for itself in the form of complete reimbursement at the contracted rate within the expected time span, allowing practices to keep their bottom lines healthy.

Via enhances revenue flow for healthcare providers.

Even practices with the best-trained claims specialists can run into problems with reimbursement at times. This is why many companies have chosen to integrate Aquina’s Via solution into their RCM process. Via allows insurance claim reimbursements to be expedited, ultimately contributing to the smooth, continuous flow of revenue that makes for a healthy practice bottom line. With integration already in place with leading electronic health records (EHR) providers such as athenahealth and Kareo, getting started is easy. Contact Aquina Health today and find out how.