Medical Claims Editing

What medical claims editing used  for?

Medical claims editing is a burgeoning industry in the United States. It offers cost-effective solutions to medical coding and billing problems, and can be tailored to suit the particular needs of individual practitioners and clinics.

With claims integration is becoming an integral part of medical practice management, it’s no wonder claims editors have become one of the most popular forms of medical billing assistance. The following article examines the different roles that medical necessity and pre-payment demonstration billing play within this lucrative niche.

What medical claims editing can do for me?

medical claim documentsMedical claims editing involves the fixing of errors and inaccuracies in medical codes and medical claims, which are then presented to health plans and payers for payment. It includes the process by which duplicate diagnoses and treatments are removed from health plans, as well as the fixing of errors and inaccuracies in payment claims and health plan claims. Medical claims editing software is designed to make the entire claims process more streamlined and error-free. Some common claims processing software features include the following:

Many claims management companies provide their clients with medical claims editing services. In addition to providing technical support to medical code and claim processors, these companies also help client insurers learn how to make their own, customized health plan benefit applications. There are many benefits of developing your own application rather than relying on a third party application vendor. For example, creating your own application eliminates the need for the use of insurance carriers, providers, and insurers.

Medical Claims Editing Benefits

One of the benefits of medical claims editing services is that they offer you the opportunity to save both money and time. Most medical claims editing service vendors charge per service page, per minute or per occurrence, instead of charging a flat rate for each claim. This means that when a health care provider claims an item on their health plan, it only requires one service request, instead of several. This also means that health plan administrators will not have to spend additional time adjudicating different claims that are received at the same time. In most cases, a service provider will not charge for the health plan provider’s time if the provider submits the claims on their own without involving the client insurer.

Another benefit that can be derived from medical necessity editing services is the elimination of duplicate claims. Duplicate claims occur when a provider makes the same claim in two different venues. When a provider edits their medical necessity claim form, they eliminate duplicate claims because the claims are written in a uniform format, contain the same information, and have the same required information.

Medical Claims Audit Software Programs

Medical claims audit programs can help a health plan administrator to make sense of the enormous amount of data that must be maintained in the various patient files within the health plan. Health plan administrators spend thousands of dollars each year sifting through paper records to identify claims that may be eligible for benefits, reclassified due to fraud, and so forth. This data must be maintained in a manner that ensures its accuracy. As such, medical necessity editing companies provide these administrators with professional and cost-effective editing solutions that eliminate unnecessary data entry while allowing the administrator to focus on important matters that require his or her attention.

Another benefit is an increase in revenue. Most health insurance providers operate on a cash basis and rely upon a steady flow of claims, many of which are rejected due to the fact that the information contained in the claims has been improperly entered or incorrect. While a company can spend thousands of dollars in claims audits and re-classified claims each year, the cost of re-aging every individual claim can quickly add up. A medical claims audit program, by contrast, can help a health care provider to save thousands of dollars in the long run by preventing claims from being rejected due to errors or misclassification. Additionally, a medical claims audit program can also assist an administrator in reducing administrative burdens.

One of the greatest benefits provided by these types of management programs is that they reduce the burden placed on the claims administrator. Because all of the work is done for the provider, this leaves less time and attention for staff members who are responsible for conducting medical necessity and pre-payment audits. This ultimately helps to save the provider money and increase efficiency at the same time. These types of management programs also provide a higher level of protection than standard practices by placing control in the hands of a third party. Because the third party has no emotional stake in a case and is not required to take a personal interest in the outcome of a case, these programs tend to be more objective, thus increasing the likelihood that management programs result in fewer cases that are ultimately rejected due to procedural errors, incomplete documentation or other factors.