Medical Insurance Claims Process

A medical insurance claim is a document submitted by a doctor after having procedures and observations done providing a list of medical services to be paid. As usual, a client isn’t involved in the medical claims process – a doctor sends a bill for medical services to a client’s insurance company which will pay for the provided services. Then it’s checked by a claims processor for adequacy according to the client’s health insurance plan and accuracy.

If everything is alright, a doctor receives payment from the insurance company. A patient can file the claim by themselves, or it can be automatically submitted after the provided services, and strictly following the Health Insurance Portability and Accountability Act requirements which preserve data security.

However, there can be some threats with health insurance claims, so the insurer can deny it considering the following points:

• Incorrect diagnosis, procedures code, errors in digits, names.
• Absence of preauthorization for a procedure
• Incorrectly defined medical necessity.
• Missing the deadlines.

Nevertheless, some insurers can offer patients particular software or online tools which eliminate the possibility of medical insurance claim denial. These programs facilitate patients’ satisfaction and help them to avoid controversies. For example, medical billing software assists patients to define the exact procedure name, code, and extra conditions for signing up.

These tools can also notify you about claim submission deadlines, so you’ll send it on time to the insurance company. Medical billing software is useful when you need to know whether your practice doctor belongs to the network covered by the insurer. Learn more how to automate medical claims to customize services and provide EMR software solutions in this article.

How Long Do Medical Claims Take to Process?

When answering the question about how long do medical claims take to process, it depends on the claim type – whether it’s cashless or a reimbursement one. The first type means that a patient has to provide a health insurance card in the hospital, so the majority of the insurance companies approve such treatment within four hours after you admit to the hospital. Although, before the visit, a patient should inform a third-party administrator in advance (three days priorly) to provide a personal membership number.

In case of reimbursement, you need to contact your insurance company, prepare all the necessary hospital bills, fill out the form to reimburse, and submit it to get approval. Generally, the processing time is around 20 days from the day of receiving the documents.

Speaking about a medical negligence claims process, it means that a patient suffers from the outcomes of a doctor’s mistake, and this document must be presented properly to be assessed smoothly without delay. There’s the time limit for this claim is three years from the day the negligence occurred, because a patient should have some time to notice symptoms or illness.

It’s important to consider the medical claims audit process that involves a systematic and detailed analysis of the filed records to assess a patient’s needs and complaints. Meanwhile, to eliminate potential discrepancies with the manual medical insurance claims process, a patient can use electronic medical and healthcare records where authorized medical services providers have access to diverse medical data of their patients.

Such tools, like Romexsoft, aim to provide a client-centered model of relationships between patients, hospitals, and health insurance companies, along with figuring out how to process medical insurance claims easily. Another option that can automate medical insurance claim processes is RPA, i.e. robotic process automation based on the AI principles. So, automation ensures executing reliable and efficient decisions, optimizing workflow, performing all tasks without errors, and guaranteeing smooth health insurance claims processing.