Are your claims delayed because of frequent inaccuracies or denials? If the answer is yes, it’s time to adopt medical claims software.
In today’s health care environment, claims must be processed with care. Even the slightest error, such as incomplete patient information or a diagnosis coding error, can lead to rejected claims, delayed reimbursement, and unhappy patients. Due to these issues, healthcare companies are utilizing more modern medical claims software systems.
But how exactly do these systems improve accuracy? In this post, we will discuss it clearly!
But before moving forward, it is important to have a clear understanding of what claims software systems are, especially if you’re new to the concept.
So, let’s get started!
What are Claims Software Systems in Short
Insurance companies, third-party administrators, and other healthcare organizations use advanced claims software systems to streamline and speed up the claims process. They leverage data analytics to support data-driven decisions, automate manual processes, and integrate with other systems.
The Accuracy Issues in Healthcare Claims
Now that you are familiar with claims software, it’s time to understand the accuracy issues in healthcare claims.
So, below is a breakdown of the main accuracy issues in healthcare claims.
Data Entry Errors
- Incorrect patient details, such as an incorrect patient name, date of birth, gender, address, or insurance ID number.
- Incorrect provider information, such as the provider’s name, address, or contact information.
- Incorrect policy numbers, addresses, or health plan information.
Coding and Documentation Errors
- Incorrect or outdated CPT, ICD-10, or HCPCS codes.
- Inconsistent codes for diagnosis and procedure.
- Failure to attach important modifiers to CPT or HCPCS codes.
- Lack of important supporting documents, like medical records or prior authorizations.
Administrative and Procedure Errors
- Services need a referral or prior authorization that has not been done or has been omitted.
- Claims that are not filed within the payer’s required timeframe.
- Submitting the same claims multiple times.
- Claims are submitted without complete general information on the form or without omitting entire process codes.
- Submitting claims for patients who did not qualify for coverage at the time of service.
Compliance and System Errors
- Outdated coding information results in incorrect codes.
- Not being familiar with the specific requirements and guidelines of each insurance payer.
- Lack of training for staff on coding standards, insurance payer rules, and the claims process.
How Claims Software Systems Avoid These Errors
When errors occur in claims processing, you may experience increased claim denials, delayed reimbursement, and other consequences affecting overall financial health. However, claims management solutions assist in minimizing claims processing errors. Here are ways they help to improve accuracy:
Automated Data Validation
Before submission, the medical claims software performs checks to identify any missing or incorrect information regarding patient demographics, provider information, insurance policy numbers, or both diagnosis and procedure codes. This process can lessen many of the manual entry errors associated with claim submission while also confirming that all required fields were filled out correctly.
Built-In Coding Assistance
Most claims management solutions also work from current coding libraries, which include help when codes are used incorrectly, expired, or mismatched. While improving efficiency, this process also prevents coding errors such as upcoding or undercoding, or using coding for variations of a procedure coded as “non-billable” or “uncoded”.
Eligibility Verification in Real Time
Insurance claims software can determine in real time, before filing a claim, whether the patient has active insurance coverage for the requested service the patient is undergoing. This allows clinics to verify real-time insurance coverage before submitting claims and also prevents denied claims based on ineligible coverage or a patient’s insurance coverage that has become outdated.
For instance, Datagenix offers fully integrated solutions on one screen, which provides a window to all the functions that are insured and eligibility-related for the patient, speeding up the entire verification process and efficiency of the clinic.
Integrated Documentation
Medical claims software integrates with Electronic Health Records (EHR), pulling relevant documentation directly from the patient’s chart to support the charges being billed. This offers an increased level of assurance that the services billed are sufficiently documented and supported by a clinical record.
Identifying Duplicate Claims
Claim management solutions can recognize and flag a duplicate before the claim is submitted. This can help avoid double-billing or submitting an identical claim more than once.
Compliance Check
Claims processing software is continually updated to stay current with regulatory changes (e.g., HIPAA, CMS regulations). Additionally, they verify against particular payer rules to assist in reducing the chance of audits and rejections.
Boost Your Claims Process Efficiency with DataGenix
Now that we know how claims software systems help healthcare organizations improve accuracy, let’s go on to the next stage. Streamline your claims process, minimize errors, and ensure efficient operations with DataGenix.
DataGenix offers a fast, seamless claims management solution that is purpose-built for the complexity of the healthcare claims lifecycle and the reduction of claim rejection risk.
So, ready to transform your claims processing? Contact us today to learn more!
