26 September 2017
eShailendra
Shailendra Malik

eShailendra

Shailendra Malik - Project Manager & Fintech Consultant

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Insurance Claims - When will the fat timeline slim down?

19 September 2016  |  3109 views  |  0

While looking for any new insurance policy, whether that is for your health, your house, your car or any item you can think of, one of the common questions you ask is how much is the claim processing time. Claims - a dreaded word for many who have bought policies for various reasons. Many insurance companies have notoriously high turnaround times for the approving and then settling claims. Let us break down how claims processes work and why they take so much time.

 

Traditional or standard claims process for Health Insurance Claims

The claims process usually proceeds in predictable steps. Before you file a claim, you must notify people who may be responsible for the accident that you've been hurt and intend to file a claim for your injuries. This increases your chances of getting a quick settlement and prevents others from later saying that your claim unfairly surprised them.

But beyond what you can do to get things working, let’s have a quick view under the hood of the Claims processing system and see what steps are usually followed in order to get things moving and system to generate the resulting claims approvals / rejections and generating the payouts.

Thanks to the inputs provided by the Salter School (they conduct special training in the medical billing and coding skills that are needed for people to become Health Claims Specialists). Let us have a quick look at the full “life cycle” of just one medical claim.

 

Step 1. Pre-registration

The medical biller or medical coder inputs the patient’s insurance information into the database and makes a copy the patient’s insurance card.

Step 2. Verify insurance information

If it’s a new patient or a new insurance policy, the health claims specialist talks with the patient to be sure the medical practice takes the insurance, and to be sure the patient understands his or her coverage.

Step 3. Record the services the patient received

Next, the doctor, nurse, or other healthcare provider examines the patient, provides a diagnosis, and performs any necessary services. The healthcare provider then records this information in the patient’s Electronic Health Record (EHR).

Step 4. Collect patient payment

At time of check-in or check-out, the patient will pay a co-pay, co-insurance, deductible, or other out-of-pocket expenses, depending on their insurer’s policy. This money goes to the medical practice.

Step 5. Assign medical codes

The medical coder reviews the patient’s Electronic Health Record and assigns diagnosis codes from the International Classification of Diseases (ICD-10). If procedures were performed, the coder assigns procedure codes from the Current Procedural Terminology list. This has to be done accurately to ensure that the provider is paid correctly.

Step 6. Submit a claim

After the codes and patient payments have been documented, the medical biller or coder can generate the insurance claim. It is then submitted to the insurance company, Medicaid, or Medicare, depending on how the patient is covered.

Step 7. Receive and post payment

If the claim has been submitted correctly, the payer will send payment to the medical practice, and the medical biller will post the payment to the practice’s account. Medical billers and coders are sometimes responsible for tracking down payments that are late or fixing claims that may have been submitted with errors.

One of the chief concerns of the medical biller and coder is accuracy. Inaccurate coding can lead to unpaid claims and late revenue for the medical service provider. Medical coders need to be detail-oriented, organized, and analytical, so that they can use a critical eye toward the procedures, diagnoses, coding, and insurance claims.

 

Now as explained nicely in the steps above seems most of these processes can be automated if the touch points are expedited with relevant automation. Many more layers of validations are added if the Insurer has introduced multi layered loyalty points program to give benefits to their insures. A diagram from the blog of insights.axtria.com explains the further layer of validations. All these layers will definitely contribute to the timeline of the claims process.

 

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job title Senior Project Manager
location Singapore
member since 2016
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InsurTech / Fintech based startups. Agile coach, IT Delivery Manager, an experienced Murex consultant and a business development professional.

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