Understanding medical claims issues in healthcare

Complexities in the medical claims process come from sources like coding and documentation, resulting in the unnecessary denial of claims.  

Understanding medical claims issues in healthcare 

Medical claims issues in healthcare organizations often stem from the intricate nature of medical coding necessary to reflect and correctly bill a patient's treatment. Errors in documentation sent from the provider can lead to discrepancies in the claims submitted to insurers. The back and forth process of resolving these claims creates an inevitable lag that causes claims to be denied or delayed. 

There is also the matter of the regulations governing healthcare reimbursements in the US healthcare system. Beyond the massive differences in coverage across insurers impacting claims, there is also Medicare and Medicaid. These changes require healthcare organizations to continuously update their billing practices and in organizations with fewer resources, this can be a difficult task to constantly undertake. 

These are two of the systemic issues that exacerbate the burden placed upon healthcare staff. While training allows for the instilling of the right procedures and protocols to follow in the claims process, there is still an opportunity for dysfunction if it's not handled securely. 

There is also the matter discussed in Proceedings of the 19th ACM SIGKDD International Conference of Knowledge Discovery and Data Mining, “Recent studies estimate that close to 30% (∼ $765 billion in 2009) of total healthcare spending in the United States is wasted, which in turn is caused by many factors such as unnecessary services, fraud, excessive administrative costs, and inefficiencies in the healthcare delivery.”

The issues in the internal medical claims process

• The assignment of higher level codes than necessary. 
• Separating services that should be billed together. 
• Misapplication of modifiers impacting reimbursement rates. 
• Submitting the same claim more than once. 
• Failure to obtain necessary approvals before providing services. 
• An insufficient review of the necessity and appropriateness of services. 
• Mistakes in adjusting claims based on contractual agreements or payment adjustments. 
• Late filing of claims that result in denials or reduced payments. 
• Mistakes during manual entry of claims data.
  
  

How to target medical claims complexities 

Advanced coding software: 

• Using software that benefits from AI and machine learning assists in accurate coding and flags potential upcoding or unbundling. 

Preauthorization tools: 

• Automated tools help streamline the approval process to verify whether services are covered before they are provided. 

Comprehensive utilization review programs: 

• Create a utilization review program to assess the necessity and appropriateness of services. It justifies patient records and treatment plans.

Data integrity measures: 

• Invest in systems that ensure accurate data entry and validation so that patient information can be validated. 

Data analytics: 

• Use data analytics to monitor claim trends and identify recurring issues. 

Collaboration with payers: 

• Regularly communicate with insurance companies through means like HIPAA compliant email to understand specific requirements and resolve issues related to noncompliance. 

Denial management process: 

• Create a dedicated team or process for managing and appealing denied claims. The team should be responsible for analyzing denial reasons, correcting errors, and resubmitting claims. 
  
  

FAQs

What is the difference between medical claims and insurance claims?

Medical claims are submitted by the healthcare providers for payment, insurance claims are submitted to insurers, at times by patients. 

What is a review program? 

A review program assesses the necessity and appropriateness of medical services. 

What are the two forms of medical coding?

International classification of diseases and current procedural terminology.