The claim submission process in medical billing is the backbone of every healthcare organization’s revenue stream. There’s just one major problem. Many medical practices lack adequate visibility into how claims are submitted, processed, and reviewed.
When claims are accurate and timely, your practice can count on reimbursements arriving as expected. When they’re not, denials and delays can disrupt cash flow. Your admin team will be bogged down with tedious work, and patient satisfaction is going to suffer.
Each stage of the claim cycle in medical billing influences how quickly your practice gets paid. If errors and delays are commonplace, it’s time to revamp the entire workflow. Here’s a closer look at how the claim submission process in medical billing should look and how you can modernize your practice’s approach with the right tech.
The claim submission process in medical billing refers to the workflow that turns a patient encounter into payment from an insurance company.
While each practice has a slightly different internal workflow, the basic premise is the same. Staff must collect patient data, capture chargeable work, submit the claim, and follow through to ensure that the practice is properly reimbursed.
The claim cycle in medical billing typically consists of six steps, which are as follows:
The first stage of the claim submission process in medical billing begins with accurate data collection. Capture complete and up-to-date demographic, insurance, and contact information before every visit.
Verifying eligibility electronically before patients arrive can prevent last-minute rejections. The result is a smoother check-in process and a better overall patient experience.
Using automated tools to identify coordination-of-benefits conflicts or missing details will help your team find and fix errors before they impact your bottom line. Similarly, you must ensure your staff members follow consistent intake procedures to prevent data errors.
Accurate charge capture ensures your practice is compensated for every service it provides. Missing or incorrect codes can mean lost revenue or compliance risks. Therefore, you need to:
When you streamline charge capture, it minimizes the risk of claim rejections and helps you maintain compliance with payer guidelines.
Once your team has coded services, the next step is compiling and reviewing the claim before submitting it to the payer. During this step, you’ll need to import patient and service data directly from your EHR or billing platform to avoid manual entry errors.
Use claim scrubbing tools to catch missing fields, formatting issues, or payer-specific requirements. Submit claims electronically in a compatible format to speed up acknowledgment and reduce delays.
Clean claims are far more likely to be accepted on the first pass. On the other hand, legitimate claims with even minor errors are going to be kicked back for further review.
Submitting claims promptly and monitoring their progress keeps your claim submission process in medical billing consistent and predictable. If you aren’t already, make sure that you send claims through a clearinghouse or directly to payer portals.
Confirm that the payer has received your claim via an acknowledgment report. Resolve rejections as quickly as possible, ideally within 24-48 hours. Implement automated submission schedules to maintain daily or weekly claim batches.
Automation ensures that your cash flow remains steady and prevents claims from falling through the cracks during busy billing cycles.
Once a payer receives a claim, it undergoes adjudication. The insurer determines what portion they’ll pay based on the patient’s coverage and their contract with your practice.
After the payment has been posted, review the electronic remittance advice (ERA) or explanation of benefits carefully to verify that you were reimbursed appropriately. Post payments promptly and flag any underpayments or discrepancies.
If you automate these workflows, you can save your staff countless hours each month and improve reporting accuracy. Additionally, you’ll be able to identify underpayment trends and gather valuable data that you can use during contract negotiations.
Even clean claims can face denials. Effective denial management prevents revenue loss and reveals patterns that can improve upstream processes. To get better at denial management, you should:
Strong denial management is critical for maintaining consistent reimbursement and improving the overall claim cycle in medical billing.
Ready to create a better claim submission process in medical billing? Here’s how:
You’ll also need to ensure that your process complies with the No Surprises Act and other regulatory laws. Following these strategies will promote better accuracy and shorten payment cycles.
Each step in the claim submission process builds upon the last. When you optimize each stage, you can boost revenue predictability and protect your bottom line.
Rivet Health will help you automate claim submission, scrubbing, and follow-up. It helps your practice keep claims clean and accelerate payments.
Schedule a demo or download an ebook to learn more.