Understanding the Medical Billing Process and How Claims Submission Works

Any provider knows medical billing can be a long, winding road. With many steps from patient intake to capturing full, appropriate payment - from payers and patients - there are multiple points throughout the process that can lead to mistakes, denials, delayed payments, or money left on the table.

In fact, almost 20% of all claims are denied and up to 60% of returned claims are never resubmitted.¹ To successfully navigate the medical billing process, avoid mistakes, and ensure accurate payment, it's important to understand what is involved and how claims submission works.

What is medical billing?

The medical billing process spans all the elements involved in accepting a patient, providing care, preparing a claim for insurers, and receiving payment.

Office staff initiates medical billing during patient intake. By carefully collecting and verifying a patient's information, staff can help reduce problems with claims submission and billing later on.

Once a patient has been scheduled, providers must verify the patient's insurance coverage. Eligibility verification - which often is done using software or going through a payer's website - helps ensure that the patient's care will be covered by their insurer. It also can provide insight into how much the patient will be responsible for and what can be billed to the insurer, allowing providers to collect copays upfront.

The medical billing process continues during the patient's care, as providers carefully document the care being provided, as well as the need for the care. That information is used by medical billing staff for claims generation and submission.

How to submit claims

Claims generally are submitted to payers electronically through a third-party clearinghouse. For providers, the goal with claims submission is to avoid mistakes in documentation so that claims are paid the first time, as denials can slow the revenue cycle or lead to claims ultimately going unpaid.

Ensuring first-pass acceptance

A strong medical billing process helps providers ensure payment on first submission. This includes verifying that all necessary patient and insurance data has been gathered and is correct. Medical care also has to be correctly coded so no information is inaccurate or missing on a submitted claim. Claims should be checked or "scrubbed" before submission to spot any errors that could lead to denials.

Claims tracking

After claims are submitted, they must be tracked to see if they are approved and paid, denied, or rejected by the payer. Claims tracking helps providers monitor their revenue cycles by allowing them to see which claims will be paid and when. It also allows them to respond quickly when claims are denied and make the necessary corrections to resubmit the claims for payment.

Managing denials

While the goal is to reduce the number of denials, it's also important for providers to manage denials after they occur. The first task with a denial is to determine its cause so the claim can be corrected and resubmitted. By using real-time revenue cycle management (RCM) data to identify the root cause of a denial, providers can identify workflow trends in their claims submission process that may be contributing to common mistakes and eliminate their primary causes of denials.

Streamlining the medical billing process

Because of the complexity involved in the medical billing process, most providers rely on medical billing software to simplify the process and reduce denials.

Inovalon's end-to-end medical billing solutions help generate claims more easily and accurately - and submit claims to all necessary payers from one dashboard - to save staff time and reduce denials. Our claims management solutions and real-time RCM analytics help providers improve clean claims, reduce errors, and continuously enhance their workflows by understanding the unique trends in their medical billing process.

Combined with front-end capabilities that verify eligibility and identify active coverage, our solutions connect every step of the revenue cycle, empowering providers to master the medical billing process. Plus, patients also benefit as they go through their care journey, since more accurate medical billing often leads to reduced time to treatment and fewer financial surprises.

Improve your medical billing process

With data-driven processes and automated technology, healthcare providers can stay on the right financial path throughout the care journey and ensure a positive billing experience for patients.

Inovalon offers a variety of software solutions to help your organization better navigate the medical billing process, improve claims submissions, and avoid costly errors. Contact us to learn more.

1. "Claims Denials: A Step-by-Step Approach to Resolution." Journal of AHIMA, January 30, 2023. https: //journal. ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution

Inovalon and design® and Inovalon® are trademarks of Inovalon, Inc.

Public link

Please use the above public link if you want to share this noodl on another website.