Optimizing Healthcare Claims Scrutiny: Ensuring Accurate Payments for Genuine Claims

Introduction

The market size for healthcare claims management is expected to grow from $15.57 billion in 2023 to $22.13 billion by 2032. There are various reasons for this increase, ranging from a rise in chronic and infectious conditions around the world to a growing demand for automation in healthcare.

Payers, including insurers and health plans, face increasing pressure to scrutinize claims more effectively. Ensuring that only valid and complete claims are approved is critical for managing healthcare costs and maintaining financial sustainability.

Effective claims management helps ensure payments are made based on accurate and verified policyholder information. Denying improper or incomplete claims is a key part of safeguarding financial health and improving service efficiency.

In this article, we outline the primary reasons for claims denial from a payer’s perspective and how claims management services can help payers streamline their claims management process to ensure that only genuine claims are processed.

Common Reasons for Medical Claim Denials

For payers, denying claims is often necessary to prevent improper payouts, especially in cases of non-compliance or missing information. The most common reasons for claims denial include:

Lack of Pre-Authorization: Some insurance plans need pre-authorization or referral for certain services or procedures. If pre-authorization or referral is not obtained when needed, claims might be denied.

Inaccurate Patient Information: A common reason for claim denial is inaccurate patient information. Examples are incorrect patient date of birth, insurance information, or name.

Timelines: It is crucial to submit claims promptly. If claims are submitted post the deadline, they could be denied.

Coding Errors: Coding errors could include, for example, outdated or incorrect codes, insufficient documentation to support codes used, or codes that do not match the diagnosis of the patient.

Exceeded Benefit Limits: Certain insurance plans may have benefit limits for some services or procedures. Claims could be denied if these limits are exceeded.

Missing Insurance Information: Examples of missing or incorrect insurance information could include wrong policy numbers, insurance ID numbers, or group numbers.

Non-Covered Services: Certain services might not be covered by insurance plans.

Challenges in Claims Scrutiny

Payers are confronted with various challenges when scrutinizing healthcare claims, ranging from administrative burdens to the complexity of managing data across multiple systems. Some of the key challenges include:

• Data Overload: Healthcare claims often involve large amounts of data, including patient information, treatment codes, and insurance details. Ensuring that all this data is accurate and complete is difficult, especially when claims are processed across multiple systems with varying standards for data entry and validation.
• Changing Regulations: Healthcare is a highly regulated industry, with frequent changes in coding standards (such as ICD-10, CPT, and HCPCS codes), compliance requirements, and payer-specific guidelines.
• Increased Risk of Fraud: Healthcare fraud is a growing concern for payers, as fraudulent claims can result in substantial financial losses. Fraudulent claims may involve billing for services that were never provided, submitting duplicate claims, or inflating treatment costs.

How Payers Can Scrutinize Claims More Effectively

In healthcare claims management, optimizing claims review processes requires a multifaceted approach. Here are 6 strategies to help achieve this.

1. Data Accuracy and Integration

Ensure accurate data entry at every stage of the claims lifecycle. By consolidating data across various systems and automating error detection, payers can reduce the risk of incorrect or duplicate claims being submitted.

2. Accurate Documentation and Auditing

Robust auditing helps ensure that supporting documents align with the claims submitted. These audits help payers identify gaps in provider documentation, ensuring claims meet the necessary standards before approval.

3. Pre-Authorization Obtainment

Payers should implement streamlined pre-authorization procedures, ensuring that every claim requiring prior approval is verified. This prevents unauthorized claims from being processed, minimizing payout risks.

4. Comprehensive Training Programs

Implement training programs that ensure payer teams stay updated on the latest coding standards, payer-specific rules, and compliance guidelines. This reduces the likelihood of errors in claims processing and ensures that claims are adjudicated according to policy requirements.

5. Denial Management System

An effective denial management system helps payers track and categorize denied claims. It allows payers to identify patterns in claim denials, such as recurring coding errors or documentation gaps, and take corrective action to prevent similar denials in the future.

Such a system also ensures that denied claims are reviewed thoroughly and resubmitted if appropriate.

6. Enhanced Follow-Ups

Timely follow-up on claims minimizes delays in payment and reduces the risk of unpaid claims.

Payers should implement systematic follow-up processes, prioritizing high-value claims and using data analytics to identify trends that may indicate issues in the submission process.

Clear communication with healthcare providers is also essential to resolve issues quickly and ensure that claims are processed efficiently.

Conclusion

By ensuring that only genuine claims are processed and paid, payers can control healthcare costs, protect their financial resources, and comply with regulations.

As healthcare costs continue to rise and the complexity of claims increases, payers must invest in strategies that improve the scrutiny and management of claims, ensuring that payments are made accurately and only for legitimate services. By adopting these strategies, payers can build a more robust and financially sustainable claims management process.

Silverskills can help you transform the claims management process by mitigating risks and ensuring accuracy in critical forms. Contact us now to avail our claims management services.