Healthcare Claims Processing: Improve Efficiency and Compliance

Healthcare claims processing is a complex process. It is a long journey that starts from the time when a patient with a health insurance cover makes an appointment for healthcare services and ends when the insurance claim is successfully processed, and the bill is settled.

Many steps in this journey involve paperwork—making a claim, sending it for review, receiving approval, determining eligibility, and final billing. But when the healthcare institution follows outdated paper-based workflows, these steps can be time-consuming, creating bottlenecks, delays and errors in manual processing.

Medical institutions all over are facing a serious problem when it comes to billing. In just about every healthcare system, there are issues surrounding the issuance, follow-up and payment of bills. Healthcare claims processing is one area that needs special attention as it can drastically improve cash flow if optimized.


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The complexities of healthcare claims processing

Healthcare claims processing involves verifying, validating, and processing of medical bills, insurance claims and supporting documents. 

Once submitted, a claim undergoes an initial review to ensure the document does not contain any typing errors or inaccurate data.

Medical claim eligibility is then checked by verifying the patient's name, insurance policy number and insurance plan validity. Next, there is a check to see whether the healthcare provider is on the insurance company's network list. There is also a check to ascertain if the medical services mentioned in the claim are covered by the patient’s insurance plan. Based on all this information, the claim is accepted or rejected. Finally, the amount to be paid by the insurance company is determined, and the patient is liable for any remaining amount.

Many things can go wrong with a claim, from spelling mistakes to missing information to incorrect coding. Healthcare providers could issue duplicate claims or send multiple bills for the same service. Or, they could be submitting claims for services they didn't provide.

The more complexities there are in claims management, the higher the cost of processing. So, it is vital to ensure that the claim is correctly filed with accurate data and zero errors and that all documentation is in order before submission to the insurance company. Accurate medical information is essential for accurate claims processing!

Challenges in healthcare claims processing

The claims process requires a large amount of information—patient's data, doctor's diagnosis, test results, insurance provider details, payment details, and more. 

Multiple stakeholders and employees must communicate and coordinate to organize the claims data accurately. Manually processing a large amount of information is time-consuming and likely to be prone to errors. 

  • Billing errors: The World Health Organization describes billing errors and healthcare fraud as 'the last great unreduced healthcare cost.' An estimated 7% of global health expenditure (approximately a few hundred billion!) is lost due to medical billing errors. 
  • Delays in claims processing: Delays affect a healthcare provider's revenue cycle negatively. They may occur due to manual data entry errors, rejected claims or in-fighting between the healthcare provider and the insurance company. An imbalance in the revenue cycle of the healthcare institution (RCM) is something hospitals cannot afford, given the slim profit margins on which they operate.
  • Medical coding errors: Medical coding errors lead to high claim rejection rates. Incorrect or mismatched ICD, CPT, and HCPCS codes result in claims being rejected and sent for investigations or resubmission. Upcoding is a type of medical billing fraud that has heavy penalties and can cause serious loss in revenue. 
  • Communication gaps: Effective communication among insurance companies, healthcare providers, and patients is necessary for a smooth claims process. When claims have to undergo a review or appeal, it makes the process time-consuming and increases the cost of claims resolution.

Steps to improve efficiency and compliance in healthcare claims processing

Digitizing the medical claims process and ensuring HIPAA-compliant digital records is the way to streamline healthcare claims management and boost its efficiency, accuracy, and processing speed.

  • Digitize patient information records

Scanning patient medical records as soon as they are received is the first step to improving efficiency in claims processing. DRS Imaging provides specialized medical records digitization services. We follow stringent HIPAA security protocols during the scanning process to manage confidential documents. For example, our newest facility in Santa Ana, California, is a boon to the region's healthcare institutions to process and convert patient records to HIPAA-compliant electronic health records.
We offer onsite scanning services to healthcare institutions to scan and capture insurance claims on a daily basis at your premises. We set up scanning equipment and a team of technicians to complete the digitization onsite so confidential information never leaves your premises.

  • Use automated data extraction technology

Automated data extraction technology makes medical claims processing smoother and helps service providers to comply with regulatory norms. It can capture key fields like patient name and DOB and make filling claim forms faster and less error-prone. Our intelligent data capture solution with auto-classification technology allows claim documents to be automatically organized and tagged for better management, storage, and easy retrieval.

  • Business process outsourcing

Billing teams within the healthcare institution may not be able to handle the complex claims processing workflow at high volumes. It's a better practice to outsource the claims processing to specialized service providers. DRS Imaging offers a HIPAA-compliant business process outsourcing (BPO) service for healthcare companies.

  • Digital mailroom automation

Health care claims may be received in paper format, via fax, email, etc. Outsource mailroom functions to DRS to digitize all incoming claims, invoices, and medical reports daily and distribute them electronically for faster healthcare claims processing.

  • Manage workflows leveraging automation

Tackling late payments, making the invoice process more responsive, or honoring claim payment timelines—claims processing workflows can be streamlined using workflow automation tools. Analyze, validate, and integrate medical data into existing business processes for greater speed and efficiency during the claims handling process with our automation partner, Hyperscience. The Hyperscience intelligent automation platform extracts printed and handwritten text from structured and semi-structured documents, such as claims forms, invoices, prescriptions, and medical reports. It reduces manual data entry, increases processing speed, and supports compliance.

  • Document management

A robust DMS helps aggregate enterprise-wide content into a centrally accessible repository. No more incomplete applications due to a lack of documentation! Scan, analyze, classify and store documents in HIPAA-compliant storage with Mercury. Our industry-leading Enterprise Content Management solution federates access to all stakeholders and ensures that information is consistent across the organization.


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In summary

Is your healthcare claims process overwhelming your in-house billing team? Is it inefficient or ridden with manual errors and information or documentation gaps?

Speak with a DRS healthcare claims processing expert today and leverage document digitization and automation tools to enhance claims processing efficiency and compliance.