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Tuesday November 16, 2021  |  Heather Shear, Sr. Manager MEDHOST Revenue Cycle Services

Inside the Lifecycle of a Healthcare Claim with MEDHOST

Inside Lifecycle Healthcare Claim EHR

From a minor check-up to major surgery, the lifecycle of a healthcare claim can be full of complexity. Complexity means mistakes are more likely to occur. Preventing errors in the claims process is the best way to ensure hospitals receive accurate payments on time and patients have a positive billing experience.

With so much pressure to capture revenue quickly, hospitals sometimes miss needed attention to detail to ensure an error-free claim. Forcing error-ridden claims through a revenue cycle management (RCM) process often results in further delays. The struggle to retain skilled front office staff can also create additional challenges in achieving prompt, complete reimbursements.

By outlining how MEDHOST Business Services helps work in healthcare, we illustrate how supplementing the RCM process with additional expertise can advance a claim's lifecycle, supporting a hospital's overall financial health.

A Healthcare Claim is Born

After patient discharge, the associated account goes through a pre-bill edit process directly within the MEDHOST system. This process generates errors on a Bill Selection Error Report (BSER), which the hospital should work on daily.

Using the BSER as a point of reference and once bill hold 'suspense' days are met, a claim is born. Having the support of a third party in this early stage can be one of the most critical steps to creating a clean claim.

Claim Arrives at the Clearinghouse

Every morning MEDHOST generates an (EDI) 837 file of accounts selected for billing. This file is then automatically transmitted to a facility's clearinghouse, removing the need for any manual processing by a hospital's team.

At the clearinghouse, another round of rigorous error checks takes place, including any payor-specific edits. Claims that are error-free enter a valid state. The clearinghouse then sends those valid claims to the payor for adjudication. If errors do exist, the clearinghouse works them for clean claim submission.

Working Claims with Errors

A clearinghouse may reject a claim for various reasons, such as Invalid patient policy information, incorrect insured relationship, other insurance as primary, and physician credentialing.

Hospitals can reduce most of these rejections by defining an eligibility process that occurs upfront before admission. If such an approach does not exist, the MEDHOST Business Office Services team can help define one.

Claims with reported errors go back to MEDHOST for review by one of our qualified billers. Reviewers apply corrections and place the claim in a valid state. MEDHOST works most rejections within 72 hours of reception.

A Claim at the Payor

Once a payor receives a valid claim, they determine whether to pay or deny the claim during the adjudication process. There are instances where partial payment and partial denial occur.

At this stage of the process, if a hospital utilizes MEDHOST Contract Management, we help determine any expected reimbursement variances using a module that integrates with a hospital's financials.

When payments post, the expected and actual reimbursements go through a review. Any accounts with variances show up on a report. This same process occurs with denials.

This entire process removes much of the burden of contract management from a hospital's business office and helps ensure accurate reimbursements.

Underpayment and Denial Management

The MEDHOST Business Services Denial Management team works every variance in a claim to determine underpayment. Where applicable, MEDHSOT will initiate an appeals process with individual payors.

In addition to appeals, the MEDHOST Business Services team will also follow up with payors on outstanding accounts receivables. This process determines if an account needs rebilling, adjustments, or is the patient's responsibility.

Automation plays an essential role in MEDHOST's day-to-day account management, helping steer the lifecycle of a claim forward with minimal manual intervention.

Accelerate Your Claims and Revenue Cycle

MEDHOST Business Services can help nurture the lifecycle of a claim and make sure it results in total payments. Comprised of patient financial and health information management professionals, we can supplement your hospital's front office team and revenue cycle management process from billing to cash posting to contract management and account follow-up.

To learn more about how we can help you streamline the life cycle of claims and collect the most accurate payments from payors consistently, reach out to us at inquiries@medhost.com or call 1.800.383.6278.

 

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