The only way to improve cash flow for new and established healthcare practices is to look after the medical claims processing side. While patient care remains the primary focus of physicians, many providers that are new to the industry hold little or no experience in handling medical billing.

In such cases, outsourcing billing and medical claims may be the best option. For providers or physicians to understand why this solution works, they must learn the complexities of medical claims processing. In this article, we look at exactly that.

What is Medical Claim Processing?

When providers render services to patients, they are paid by sending bills to insurance companies that cover those services. First, all claims are prepared with a specific ICD and CPT code associated with each service rendered. Within these claims is information such as plan coverage and patient demographics. Every claim is then verified by insurance providers and the physicians are reimbursed accordingly.

Medical Claim Billing in Depth

Medical claims processing is not a walk in the park. It is a complex task that requires an individual with professional skills who gives great attention to detail. They must also have extensive training in new coding techniques, excellent communication skills, and knowledge of prevailing healthcare trends. Claims must go through rigorous technical protocols and pass industry standards to be qualified by the payors.

Clearinghouses

The second step in medical claims and billing is clearinghouses where processed claims are sent. A clearinghouse is a third-party hub that works as a bridge between the payor and provider. Clearinghouses sort claims, review them for errors, format them according to industry standards, and send them to insurance carriers.

Benefits Explanation

Once claims are evaluated, the insurance companies paid the providers or reject claims with errors. They also provide an explanation of benefits (EOB) that details information such as treatment dates, charges, diagnosis, reimbursed amount, and patient’s financial responsibility.