A clear overview of the claims process, from submission to payment, and how each step affects your practice’s cash flow.

The process a claim goes through from the time you see the client all the way to receiving payment is extensive…for a reason. Insurance companies have multiple layers of examination for each claim to guarantee they are not wrongfully paying out on a claim.  Below are the steps a claim goes through once it is submitted to insurance:

1. File claim. The first step of the healthcare claims process is submitting a claim, either as a physical copy or digitally. If a hard copy claim is submitted, it must be translated into a digital format.
2. Initial review. Once the insurance carrier receives the claim, they review it to ensure it has been filed within an appropriate filing period. Typically, a software algorithm also searches for duplicate charges or inaccurate data.
3. Verify member. The insurance carrier verifies member eligibility by checking their system to see if the member has an active insurance plan.
4. Verify network. The insurance carrier checks to ensure services on the claim have been performed by a member provider in their healthcare network.
5. Apply negotiated price. Insurance companies have contracts with providers in their networks that establish fixed-price discounts. These negotiated rates are applied once the member and network are verified.
6. Verify member benefits. One of the lengthiest parts of the process is when the insurance company verifies membership details, like whether the member’s benefits cover the services, which benefits apply where, and what percentage of cost-sharing the member and their employer are responsible for paying.
7. Verify medical necessity. Once the member, network, and benefits are verified, the insurance company decides whether the services listed on the claim are necessary for the patient’s medical needs.
8. Evaluate claim risk. The company’s software automatically flags claims for potential insurance fraud.
9. Issue payment to provider. Having authenticated the validity of the claim, the insurance company sends payment to the provider.
10. Communicate Explanation of Benefits (EOB) to members. Members receive an EOB statement—not a bill—that details the total cost of services billed, how much insurance covers, and what they can expect to pay for coinsurance.

The average claim processing time can take from 14-30 days, depending on the insurance company, and then payments are issued.  If there is any glitch in the process, it can delay payments for months.  A professional biller can help avoid issues by utilizing some basic guidelines, as follows:

1. Verify insurance plan is active and covers services provided.
2. Verify prior authorization has been obtained if needed.
3. Verify basic patient information is accurate on claims including full name, date of birth and address.
4. Verify provider information is accurate on claims including full name, address, NPI and Taxpayer ID.
5. Verify CPT codes are billable and that service types match diagnosis codes.
6. Verify diagnostic codes are billable.
7. Verify correct place of service code to match service type and location.

At Simplicity Billing Services, our staff helps guide our clients through the arduous claims process to maximize revenue and minimize denials and delays – we keep it simply for you!