Healthcare providers often find it overwhelming to navigate the complexities of medical billing. Claims adjudication is an essential part of that process, as it plays a primary role in making sure that insurance companies or payers provide accurate and timely reimbursement.
In this article, we’ll clarify the concepts of claims adjudication and their importance for healthcare providers like you. Let’s explore how this process can affect your revenue cycle management and gain some valuable insights along the way.
What Is Claims Adjudication?
What is claims adjudication, exactly? To put it simply, claims adjudication is the careful review and assessment of healthcare claims that providers submit to insurance companies or payers. Its purpose is to determine whether these claims are valid or not.
Providers create a comprehensive claim when they render healthcare services to patients. This claim encompasses various details, such as patient information, the services rendered (including diagnosis and procedure codes), and the corresponding costs. Here’s how it works:
The Claims Adjudication Process
1. Claim Submission
Healthcare providers send claims to insurance companies or payers in order to request reimbursement for the services rendered to patients.
2. Eligibility Verification
Insurance companies conduct eligibility verification to confirm whether a patient had the necessary insurance coverage at the time they received medical services.
3. Pre-Adjudication Review
During the pre-adjudication review, the claim is examined to identify any errors, missing information, or inconsistencies that may need attention. If any problems are found, the company will reject the claim and notify the providers so that they can make the necessary corrections to resubmit it.
4. Adjudication and Determination
In this stage, insurance companies carefully review the claim to determine its validity. They compare it with the policy terms, medical billing and coding guidelines, and medical necessity requirements.
5. Payment Calculation
When your claim is approved and covered, the insurance company will calculate the reimbursement amount using the current rates and fee schedules that have been previously established.
6. Claim Resolution
Once the claim has been reviewed and settled, the healthcare provider will receive an explanation of benefits (EOB) that outlines the decision made regarding the claim. The EOB provides details about your payment information and any responsibilities you may have as a patient, such as copays or deductibles.
7. Payment or Denial
After a complete and comprehensive review, the insurance company will either provide payment to the healthcare provider for the services that are covered, or they will deny the claim if it doesn’t meet the necessary criteria for reimbursement. There are several reasons why denials can happen, including issues with medical necessity, coding errors, or limitations in coverage.
What Is Claims Adjudication to a Healthcare Provider?
As a healthcare provider, you know that claims adjudication plays a vital role in managing your revenue cycle effectively. It has a direct impact on your cash flow and the reimbursement you receive for the services you offer to patients.
Managing the process can be complicated, demanding large amounts of your valuable time. Handling the challenges of claim denials or rejections can increase the administrative workload for your practice still further. So what can be done about it?
Redefine Claims Adjudication for Your Practice
Partnering with a specialized medical billing service like Medbill can make a huge difference in ensuring a smoother and more efficient claims adjudication process. The team at Medbill is specially trained for handling the complexities of claims adjudication, minimizing denials, and maximizing your revenue cycle.
By partnering with Medbill, you can dedicate your attention to providing excellent patient care while your trusted team manages the delicate tasks involved in medical billing and claims management.
To learn what superior claims can do for you, contact Medbill today.