9 Essential Tips For Accurate Medical Claims Submission

Making a medical claim is often fraught with red tape and bureaucratic bottlenecks, which make it a fairly daunting process. This holds true whether you’re a healthcare provider or part of the administrative staff. 

That being said, there is no way around this scourge, and if you want to get paid, you need to get your claims processed efficiently and accurately. It’s not just about getting paid either, but about minimizing errors and improving the overall efficiency of the healthcare system.

In this article, we take a look at some tried-and-tested strategies, and best practices to make your medical claims submissions as precise as a surgeon’s scalpel.

1. Know The Basics: Understand The Claim Form

Start with the basics. The standard form used for health insurance claims in the U.S. is the CMS-1500 for professional services and the UB-04 for hospital services. Each field on these forms has specific requirements. 

Make sure you know what information goes where from the patient’s demographic details to the specifics of the diagnosis.

The CMS-1500 form is designed to capture all necessary, and basic information pertaining to a patient, in order to process a claim efficiently. This includes the full name, address, birth date, and insurance ID number, among a few other things.

The UB-04 form, while similar in purpose to the CMS-1500, requires additional information reflecting the complexity of institutional care. This form consists of numerous fields, or form locators, each designed to capture data critical for hospital billing

2. Stay Updated On Billing Codes

As most people who’ve worked in this business can tell you, the billing codes change, and they change often, wreaking havoc on systems and processes when they do. 

To start with, the ICD-10 updates annually, while the CPT codes update periodically too, and using outdated codes is a common pitfall, resulting in claim rejections, delays, and a host of other inefficiencies that cost time and money.

The best way to avoid this is by regularly checking for updates from the American Medical Association, as well as the World Health Organization. You can also consider subscribing to coding updates or using a medical billing software with real-time updates to save on a ton of manual work and hassles.

3. Double-Check Patient Information

A simple typo in a patient’s name or an incorrect date of birth can significantly delay claim processing. Always cross-reference the patient’s information with their insurance card at each visit. 

It’s crucial to also verify the spelling of complex or unusual names and confirm any changes in patient details like marital status updates, as these can affect insurance coverage and claims. 

Such meticulous verification is a straightforward yet powerful method to ensure accuracy and prevent delays.

Fortunately, there are plenty of advanced AI-enhanced tools that pick up the slack these days, identifying errors by themselves, and bringing attention to facts that may be incorrect. In the process, they help minimize errors substantially, while improving the overall pace of making claims.

4. Verify Insurance Coverage Beforehand

Before providing any services, verify the patient’s insurance eligibility and benefits. Insurance details can change unexpectedly, and services not covered can lead to unpaid claims. Use electronic verification tools if possible, they can provide real-time updates on coverage limits, copays, and deductibles.

To enhance the efficiency of this process, consider setting up automatic reminders for front-desk staff to verify insurance at every visit.

Additionally, maintain a direct line of communication with insurance representatives to clarify ambiguities about coverage, especially for complex cases or new procedures. This proactive approach ensures all parties are informed and can prevent costly billing errors and patient dissatisfaction.

5. Use Technology to Your Advantage

Leverage technology to streamline your claims process. Electronic Health Records (EHR) and Electronic Medical Records (EMR) systems can integrate with billing software to ensure that the clinical side and the billing side of your practice are in sync. 

Features like automated code checking can catch common errors before they become a problem. Similarly, advances in AI and machine learning, and their convergence with EHR and EMR systems stand to unlock substantial value for practitioners, in terms of efficiencies and reduction in overheads.

Consider investing in interoperable systems that save plenty of time, while minimizing errors when communicating between different healthcare providers and insurers. Price transparency solutions are also opening new avenues for verifying that reimbursement contracts between healthcare providers and insurers are configured correctly.

6. Be Specific With Diagnoses & Procedures

When it comes to medical billing, vagueness is your enemy, this is especially the case in radiology medical billing. Specify exactly what diagnoses were made and what procedures were performed. More detailed claims are less likely to be rejected. 

For example, instead of coding for a generic “stomach pain,” specify whether it was “acute gastritis” or “chronic gallbladder disease.” Failure to do so can lead to more confusion and an increased possibility of claims getting rejected. 

Complexities increase manifold when dealing with specialties such as cardiology, which requires a deeper understanding than most others. Knowing and understanding the different codes for different procedures is cardiology medical billing 101, and the same holds true for other specialties and services as well.

Here again, modern EHR and EMR systems, enhanced with the power of AI can add substantial value, with the use of autofill functionalities, and error detection systems. They help minimize manual effort to a great extent, and with it goes manual clerical errors which are the scourge of modern healthcare. 

7. Master The Art of Documentation

Documentation is critical, especially is sensitive practices like oncology medical billing. Detailed records can defend a claim against denials for insufficient information.

Every service provided must be documented and justified in the patient’s medical records. If an insurance provider queries a claim, robust documentation can be the difference between an accepted or rejected claim.

Ensure that your documentation includes not just the facts but also the context and rationale behind every decision. 

Detailing the clinical reasoning that leads to a diagnosis or treatment choice can further substantiate the necessity and appropriateness of the services billed, thus reinforcing the legitimacy of the claim. This comprehensive approach can be particularly crucial in complex cases.

8. Follow Up On Claims

Don’t just send off a claim and forget about it. Follow up! Check the status of your claims regularly. If a claim is denied, find out why as soon as possible, and address the issue. 

Sometimes, a quick correction and resubmission can resolve the problem. Incorporate a systematic tracking system that alerts your team when a claim remains unsettled beyond a typical processing time. 

This system can help prioritize which claims to follow up on first and ensure none are overlooked. Regular audits of these processes can also identify patterns in denials that can be addressed to improve future submissions.

9. Understand & Appeal Denials Properly

Understanding why claims are denied is fundamental to correcting issues and preventing future mistakes. Common reasons include incorrect patient details, outdated codes, and coverage issues. 

Learn how to write an effective appeal letter that clearly states why the claim should be reconsidered, referencing medical policies and providing additional documentation as necessary. Keep in mind that denials are a part and parcel of this industry, the key is minimizing them as much as possible.

Additionally, ensure each appeal is tailored to address the specific reasons cited for the denial. Use concise language and include pertinent information such as date and service codes. 

Providing a timeline and summarizing previous communications can also strengthen your appeal, making it easier for the reviewer to understand the context and urgency of the reconsideration.

Conclusion

Accurate medical claims submission isn’t just about getting paid, it’s about efficiency and patient satisfaction. 

These tips are just the beginning. Implementing these practices can lead to more accurate claims, fewer denials, and a smoother operational flow in your medical practice. Remember, in the world of medical billing, precision and attention to detail are as important as in medical care itself.