The Simple Anatomy of a Claim That Gets Paid

Certificate of CompletionThere are two primary reasons a claim doesn’t result in a payment. Either the payor doesn’t receive the claim, or the payer denies payment due to a defect in the claim--such as incomplete or incorrect data, or lack of documentation supporting the services billed. Since claims are often too costly and time-consuming for practices to appeal, revenue is essentially left on the table. Obviously, this isn’t an ideal approach. Work was performed and a service provided, but an administrative issue dooms the provider to non-payment. Unless, that is, new tactics are adopted. Consider that a medical claim is simply data– “I saw this patient (patient demographics), on this day (DOS encounter data), they have this problem (coding), I did this for them (coding) and they have this insurance (insurance data).” Get those five pieces of data right and you will get paid; get any of them wrong or miss any data elements, and getting paid is a long, hard trek. Sounds simple, right? It is, conceptually. But actually getting all the data elements complete and accurate in a busy practice environment is a constant challenge. This is where a good claims editing system comes in, as a tool or set of tools that can be deployed to assure data integrity. Smart—that is, automated--claims editing applies pre-adjudication edits to claims specific to practice, payor mix, and state. This gives the practice a newfound ability to spot and fix errors before the claim is submitted. Here’s another consideration to keep in mind: payors all have automated systems that analyze claims to flag errors and trigger denials. Shouldn’t providers use intuitive tools to keep up, as well—and more importantly, to maintain reimbursement? This technology isn’t available to providers in traditional practice management systems, which are designed to accept whatever data is put in them, whether the data is inaccurate or incomplete. However, savvy practices are increasingly bringing in a revenue cycle partner that offers state-of-the-art claims editing technology, as well as experienced billing experts, to help them improve clean claim rates and reduce denials. In this new era of healthcare, it’s time for practices to move beyond passive acceptance of claim denials. With automated claims editing, they can—and get paid for all of what they’ve earned.

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