Majority of the payers these days struggle with a complicated system of claims processing which result in numerous errors. As this directly impacts practice revenue, physicians would benefit tremendously by bringing in accuracy, efficiency and visibility into their claims analysis and management process.

Industry Standards State

  • Recent study of insurance payment patterns depict that accuracy of claims processing by commercial carriers was 84%, hence 1 out of every 6 claims processed are paid incorrectly
  • Average claims-processing error rate for 2010 and 2011 was 19.3%, an increase of 2% over the previous year
  • In 2011 it was estimated that by eliminating claim payment errors the health care system can save $17 bn. per year

Briefly understanding the payer’s administrative system-

  • Once claims are submitted the patient’s benefits and eligibility is determined. The payer applies pricing edits which reduce physicians’ billed charges on submitted claims
  • Payer proprietary edits are applied and payer makes adjustments to the claim determining whether the specific codes listed on a claim are eligible for payment
  • Auto adjudication is completed determining the final payment and Explanation of benefits (EOB) is generated and sent specifying the paid amount of the medical service provided

Inaccurate claims include partial payments without explanation, underpayments and overpayments. The payer’s first time EOB payment accuracy rate can have a considerable impact on a physician’s practice costs.

Challenges physicians encounter while auditing inaccurate claim payments -

  • There is no clear industry standard to the number and types of unique payer-specific proprietary edits used and additionally as edits lack a general sense of transparency; it is difficult for physicians to determine if a payer edit was applied appropriately
  • Practice staff while auditing claim edits due to complexity of the claim edits system face economic and practical challenges; resulting in large number of payer errors getting undetected
  • Physicians need to tackle increasing compliance requirements, documentation, and moreover claim analysis issues are becoming highly complex with limited visibility into problem areas

How do inaccurately paid claims adversely impact physicians?

  • Physicians require to communicate a number of times with payers, moreover it takes a considerable amount of time to finalize the right payment and the final patient balance
  • Delayed and inaccurate payments may hinder the physician’s ability to accurately determine the patient’s financial responsibility
  • Initial inaccuracies may prompt multiple data entries, additional administrative costs, auditing and collections expenses for the physician’s practice.

Increasing your payments with MBC’s claim management process

Physicians can avoid the extra expenses and increase claim payment accuracy without investing their valuable time with the help of a billing specialist. MBC is constantly finding ways to increase accuracy, efficiency and visibility for its clients with its claims analysis and management process-

Evaluate all payer contracts – to ensure physicians receive the correct payments, MBC helps physicians review all payer contracts, including the associated fee schedules, available claim edits, payment policies, and other payment rules before signing any contract.
Constantly review and audit claims - for timely and accurate payments MBC identifies all inappropriate claim denials; communicates with the payer‘s regularly and initiates claim appeals when required.
Challenge inappropriate claim payments –in an effort to correct payer inaccuracy and also reduce future denials and costs; MBC challenges and appeals claims that have been inappropriately denied by payers.

MBC the largest consortium of billers and coders has been providing medical billing including denial management services across US for over a decade now; which meet national and local requirements for medical necessity and complies with commercial claims stipulations.

MBC aims to stop inaccurate claim payments before they start by constantly monitoring claims submitted and identifying opportunities which help improve accuracy, compliance and productivity.

Published By - Medical Billers and Coders
Published Date - May-15-2013 Back

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