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Claims Management News

How Payers, Providers Could Streamline Medical Claims Management

Payers and providers may need to boost training and medical documentation processes while reducing denial rates to streamline medical claims management.

By Vera Gruessner

Successful medical claims management and processing is not always easy to garner for health insurance companies due to a lack of training among insurance agents, missing or inaccurate documentation, and the general time-consuming aspect of resolving claim denials between payers and providers.

Medical Claims Denials

Health insurance executives may find that billing experts exhibit a lack of training in streamlining medical claims management because they’re being stretched thin between their focus in value-based care reimbursement such as bundled payment models, new healthcare delivery reforms including accountable care developments, and a greater emphasis on population health management.

Michelle Tohill, Director of Revenue Cycle Management of Bonafide Management Systems, provided her advice on improving medical claims management and handling claim denials. When finding staff members lack training, some areas that need to be addressed is greater education in understanding medical documentation and ensuring forms are completed accurately. Also, staff members may need to be trained on sticking to deadlines and returning medical claims in a timely manner.

When addressing inaccuracies or incomplete documentation, payers could offer more resources and education to billing staff within their provider networks in order to streamline medical claims management and processing. Payers could utilize portals and their own websites to provide resources on how to document clinical diagnoses codes and other procedures.

To reduce errors in medical documentation, automation technology may also be beneficial for payers and providers, said Kimberly Branson, the ‎Vice President of Business Architecture & Strategy at Medica.

From a core administration perspective, the core responsibility of a health plan or a payer is to finance healthcare,” Branson told last February. “The way that it’s done is pretty complex between the payer and the provider. Having information technology that helps to automate workflow and automate the transfer of information within and in-and-out of a health plan is critically important.”

According to the National Health Insurer Report Card from the American Medical Association, the insurer Aetna denied 20.9 percent of claims in 2012 while Anthem Blue Cross Blue Shield denied 27 percent of claims and Cigna denied 27.9 percent of claims. Humana and the Medicare program had lower claim denial rates with Humana rejecting 14.1 percent of medical claims and Medicare denying 11.1 percent.

To streamline medical claims management, payers may need to work with providers to reduce and resolve claim denials more quickly. Identifying the root causes of claim denials may help. When providers target the reasons why claims were denied, identify a list of common reasons, and work to improve their medical claims management processes, the rate of claim denials should decrease.

An Advisory Board study from 2014 found that 90 percent of claim denials may be prevented by changing medical claims management workflow especially with regard to patient registration and claims submission processes.

Some of the typical reasons behind claim denials include missing data especially patient demographic information, services not covered by the health plan, duplicate submissions, and the deadline for the submission passing, according to the 2013 MGMA health insurer report card.

One way to move forward in reducing claim denials and streamlining the whole medical claims management process for both payers and providers is to create a proactive revenue cycle where medical billing staff ensure that claims are error-free before they’re sent out the door. Additionally, practices could incorporate tools that show whether a patient is covered by the provider before they come in for a visit.

Payers spend an excess of time approving prior authorizations and requests for their members as well. Payers often end up requiring more information, which is sent by phone and fax. However, by incorporating provider portals, information requests can be more straightforward and accomplished more quickly since the necessary documents can be found directly on the portal.

When payers and providers work together and incorporate solutions to streamline medical claims management processes, the entire healthcare revenue cycle should gain greater efficiency.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

Time, Commitment Required for ACO, Value-Based Care Success


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