The Basics of Medical Claim Adjudication For Businesses

 Medical claim adjudication is a critical function in the health insurance industry, as it helps to determine how claims are paid out and if coverage applies. Understanding the process is important for businesses that want to ensure their claims are handled efficiently and accurately. In this guide, we cover the basics of medical claim adjudication, including what occurs during the process and how to use technology to automate the process.

What is Medical Claim Adjudication?

Medical claim adjudication is the process of validating and determining the amount to be paid out for health insurance claims. During this process, insurers calculate the allowed coverage amount and patient responsibility, adjust the allowed amount if applicable, and determine how payment should be distributed. The goal of the process is to pay out claims in a timely fashion accurately.

What Does a Medical Claim Adjudicator Do?

A medical claim adjudicator is responsible for the timely and accurate processing of healthcare claims. They are responsible for collecting information from healthcare providers, insurers, and patients to verify insurance coverage, determine accurate allowed amounts, detect fraud, and ensure payments are distributed correctly. Adjudicators must also meet strict deadlines in order to maintain compliance with regulations.

Steps to the Medical Adjudication Process

The medical adjudication process involves several steps. First, the claims adjudicators receive and review the claim submission. This is typically done electronically but can also be done manually. After that, they research the insurance and documentation of the patient’s medical history to verify coverage and allowed amounts. Depending on state requirements, they may then contact a provider on behalf of an insurer to discuss questions or discrepancies. The process concludes when payment is made, or a denial letter is issued.

How Technology Helps Streamline Medical Claim Adjudication

Modern technology has helped streamline the adjudication of medical claims, reducing bottlenecks, speeding up payments, and improving accuracy. Automated adjudication systems can sort through large data sets to quickly identify and correct errors in the claim information — eliminating manual research-intensive steps and complexities of a paper-based system. By taking advantage of configurable rules and artificial intelligence-based analytics, businesses can achieve faster reimbursement times with fewer denied claims.

Common Errors in Claims Processing and How to Avoid Them

A common problem that businesses may encounter when submitting a medical claim is incorrectly completed or partially filled-in forms, incorrect procedures billed, and duplicate claims. To avoid these errors, businesses should take a proactive approach to prevent data entry errors, such as double-checking patient information, verifying accurate billing codes, and correctly entering the provider’s name, address, and contact information. Additionally, businesses must make sure to verify their coverage with their insurance provider before submitting a claim and keep updated on changes in procedures and protocols for filing claims.

These errors can also be prevented with the implementation of a specialist who manages the billing cycle for the practice. These entities can be clearing houses, in-house personnel, or Medical Billing Companies. These companies handle the billing cycle, review documentation, submission of claims, code auditing, and the event of claim adjudication.

Get in touch with one today.