Reducing Medical Claim Denials Through Automation Technology

Medical claims management and processing is usually a challenge for health insurance companies because lack of training among billing staff usually results into missing and inaccurate documentation. Resolving the problem of claim denials between the payers and providers can be complicated and time consuming.

Medical claims management and handling claim denials can be streamlined by providing training to billing staff who have to focus on different aspects in value-based care reimbursement like bundled payment models and new healthcare delivery reforms. When providing training to staff members who are handling the claims, it is important to provide them with better understanding on medical documentation and making sure that forms are completed accurately. It is also important for staff members to realize that medical claims have to be returned in a timely manner.

According to Kimberly Branson, vice president of Business Architecture & Strategy at Medica, one of the options to reduce mistakes in medical documentation is automation technology. The way that claims are done is pretty complex between the payer and the healthcare insurance provider but through information technology, workflow can be automated. Automation will make the transfer of information within and in-an-out of a health plan more efficient and accurate.

Some of the common reasons why claims are denied include missing data like patient demographic information. There are also instances when the service is not covered by the health plan or the deadline for submission has lapsed. By creating a proactive revenue cycle that will ensure that claims are error-free and there are not duplicate submissions, claim denials can be significantly reduced.

When payers require more information, staff members usually send the data through phone or fax. If there is provider portal, information requests can be accomplished faster since the necessary documents can easily be determined through the portal.

Effective insurance workflow is very important so that the process of medical claims can be streamlined. Confusion is very common during medical claims because of the number of staff working on a single claim. Sometimes the employee in the workflow path does not know what to do next because it has not been defined clearly. Improving insurance workflow will ensure that the staff knows what to do.

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