How to Improve Your Medical Claim Processing Cycle

Touseef Riaz

March 18, 2021


Regardless of how well your medical team performs in the office, you cannot leave the doors and lights open in your office just because of the quality of patient care you provide. Note that it is your main responsibility to manage your finances. You may think that the increasing challenges of higher provider costs, a volatile and dynamic healthcare market, and patient debt are insurmountable.

However, it is worth noting that this is precisely why medical claim process cycle management and improvement are important for your medical practice. There is no doubt that managing denials, scrubbing or resubmitting medical claims, and increasing collections, are some of the basic medical claim process cycle activities that your practice must accomplish.  

If your business fails to track the income you generate, you can’t stay afloat while other medical practices continue thriving and growing. Also, you should know that revenue cycle management and the medical claim process cycle are dynamically evolving under an increasing value-based approach to patient care in the age of digital innovation.

This is why most providers, from single-doctor practices to larger hospital systems, are quickly learning to adapt to this dynamic environment. So, it is essential to understand your medical claim processing cycle.

Here is how you can improve and streamline your medical claim process cycle.

Obtain Prior Consent from Your Patients

Did you know that it is mandatory for your patients to get themselves timely approved for the claim? This is especially true if they need certain drugs in the long term. However, note that the only exception to prior approvals is emergency medical care.

So, keep in mind that prior approval of a drug or procedure doesn’t necessarily mean that the relevant insurer will cover all the costs. This is why it is essential that providers and patients review any doubts or questions about coverage beforehand.

Denial Management

How frequently are medical claims rejected for medical services provided by your facility? Keep in mind that if your quarterly report indicates a decline in sales because of too many rejected applications, you have to investigate. It is no secret that properly implemented denial management helps boost profits when funds have been slow because of problematic claims and improve the medical claim process cycle.

Your medical practice should work in order to lower denials by paying attention to some of these factors.

Eligibility and Benefits

Before the visit, you should verify eligibility as well as benefits coverage, confirm insurance, and check for secondary and tertiary insurance. You should also obtain authorization if needed.  

Also, it is important to get a copy of the back and front of the patient’s insurance cards at each visit for verification.

Procedure Codes

It is essential to use a valid procedure code as well as a modifier for services that you have provided. Also, make sure that you have a valid NCD code.

Changes to Diagnosis Codes

You should stay on top of all new, changed, and deleted diagnosis codes.

Also, it is worth noting that you may notice specific patterns like too many rejected claims when certain individuals work together or you see billing mistakes and issues for certain kinds of medical procedures or members of your patient population.

Did you know that by considering these medical billing issues and their impacts on your claim processing cycle, you can recover revenue that may have been ignored because of improper insurance claims?

Streamline Medical Claims Processing

You probably know that filing individual medical claims is time-consuming and tedious. This is especially true for specialty providers that need to file hundreds of medical claims every week.

This is why streamlining your medical claims processing is one of the best ways to improve your medical claim process cycle and billing productivity. Note that mass claim creation and filing enable providers to file claims in bulk, according to the payer.

Use Software Solutions for Streamlining Revenue Cycle Management

There is no doubt that digital solutions, such as revenue cycle management software as well as online patient portals, are essential for streamlining patient payments and communication.

For example, did you know that cloud-based RCM software provides medical providers with the unique ability to aggregate medical claims filing? They also allow you to aggregate invoicing and payment transactions, patient data, and appointment scheduling all in a single place.

However, it is worth noting that if you run a large organization, you should outsource the RCM process to a reliable medical billing vendor. If your practice has limited expertise in RCM, you can also benefit considerably from relying on outsider parties for this task in order to focus on your core competencies.

Timely Accounts Receivable Follow-up

You may know that accounts receivable pile-up is among the top causes of ineffective medical claim process cycle and management. In order to ensure that all denied claims are tracked as well as appealed in a timely manner, you should employ a dedicated and talented accounts receivable management team to get the best results.

From analyzing and prioritizing to collecting and appealing payments, the team will handle all the operations effectively and proficiently.

Note that if your healthcare organization does not have a dedicated accounts receivable management team, you can partner with a professional medical billing company.

Enhance Quality Control

It is no secret that eliminating claim errors and mistakes is critical to improving the medical claim process cycle. However, keep in mind that the billing and collections processes do not stop once the medical claim is approved. If you use generally accepted accounting practices (GAAP) in order to post and record payments, you can keep a close watch on your cash flow.  

And one of the best ways to make sure that account balances are accurate is to establish a deposit log for all receipts that you can forward to your billing department. It is vital that this log includes all information required to ensure proper posting. This will make it easy and quick for reviewers to confirm that the correct payment amount is posted to the account.

Outsource Difficult Collections

You may have been hesitant or reluctant to outsource any part of your billing process. However, keep in mind that outsourcing difficult collections are one of the best ways to improve your bottom line.

Did you know that an RCM services provider has the staff and time to dedicate to the collection of all problematic payments? This will save your medical practice time and improve your medical practice revenue at the same time.

Note that these services are often the best choice for providing your patients with manageable solutions while receiving understanding and compassionate service. And this will not only improve your medical billing productivity but also enhance the reputation of your medical practice.

Set Goals and Closely Monitor KPIs

When medical practices perform revenue cycle assessments in order to improve their medical claim process cycle, they always ask collectors, billers, and cash posters, whether they have productivity goals. There is no doubt that successful revenue cycle management depends on measuring important rates and statistics.

After that, you have to set regular goals in order to measure the efficacy of workflow changes as well as make updates to existing protocols. It is no secret that employees who have set objectives and goals are more motivated than others to achieve these goals. On the other hand, without set expectations, your billers can have wildly different levels of productivity.  

This is why creating goals and tracking progress will help you make more informed decisions on whether you are adequately staffed and whether your processes have to be changed, amended, or streamlined in order to help your cash posters and other staff stay up to date.

Train and Educate for Success

You probably know that every insurance provider has a unique set of rules. For example, one insurer may require chart notes with medical claims for all new patients to establish a primary care relationship. On the other hand, some might need chart notes for non-standard treatment protocol or follow-up care.

This is why training and development programs must include components that allow billing departments to quickly and easily access filing requirements and also access patient files in order to ensure that each carrier has the information needed to expedite medical claim processing after submission.

Identify Areas for Improvement

By identifying the areas that your medical billing workflow lacks, you will be able to work towards solutions that improve and streamline the medical claim process cycle. For example, your software provider should offer you options to view red flags, while your RCM service provider must help you identify common or routine causes for denied medical claims so that your practice can start to improve in these areas.

Final Thoughts

There is no doubt that back-office functions and roles in the medical claim processing cycle are critical to the success and growth of your organization. And it is clear that outsourcing medical billing operations are one of the best ways to improve your medical claim processing cycle.

By outsourcing these functions, you can enjoy many benefits. If you are looking for a competent and experienced company to outsource, you should look no further than UControlBilling, a one-stop shop for all of your medical billing and coding needs.

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