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Archive for Medical Claims Processing

Medical Claims Processing: What Does a Medical Claims Processor Do?

Caring for the health of your patients is the most important part of your business. That is why millions in the healthcare industry rely on specialized professionals, like Apex EDI, to manage the complex interactions between healthcare providers and medical insurance companies. Allowing others to handle this responsibility for you lets you focus your attention where it should be, on the patient.

When a patient seeks medical care, behind the scenes Apex EDI manages the transaction between the provider and the insurance company. We obtain a record of medical services provided from the office, clinic, or hospital and we handle the responsibility of sending healthcare claims out to the patient’s insurance company.

Medical Claims Process can be complicated

The medical claims process is a complicated, yet a crucial component to making sure you get paid accurately and quickly. The knowledgeable staff at Apex EDI understands medical coding, billing terminology, compliance requirements, common errors and the best ways to work with a variety of insurance providers from HMOs, PPOs to Medicare and Medicaid.

We know that payers can deny or reject claims when errors are made. We want to work

with you to help make sure your patient receives the best care possible, receives the insurance coverage they are entitled to, and you get paid in full. There’s nothing more frustrating than dealing with financial payment discrepancies during a health care crisis.  

Working with a medical claims processor can have a positive impact on your healthcare practice and your financial bottom line. Contact Apex EDI to request a free demonstration today.

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Medical Claims Processing: Medical Claims Processing Laws

Between dealing with physician, patient, and insurance data, staff in your billing department will be handling a lot of sensitive information. This is why it’s important for everyone in your billing department to understand the laws protecting that information and what they and the practice are responsible for, when it comes to the laws surrounding medical claims processing. Here are just two of the most important medical compliance agencies that medical billing specialists should be aware of.


HIPAA Regulations documents on a desk apex edi

Many people are at least aware of the existence of HIPAA, a set of guidelines that governs the way that medical information is protected. While HIPAA covers many aspects of patient protection, the part that applies most pressingly to those working with medical claims is found in Title II, which governs how and with whom patient data can be shared. HIPAA simplified the process of medical billing by providing universal identifiers for providers, employers, and patients, and by standardizing the requirements for electronic claims processing software.

Billing staff will be required to stay in compliance with HIPAA by protecting patient information and not sharing it with unauthorized parties. Medical practice employers should review HIPAA with all of their employees during the onboarding process.


The OIG was established to enforce HIPAA and prevent medical fraud. To remain in compliance with OIG, it’s important that medical billing staff refrain from activity that may be considered fraudulent. Fraudulent activity is generally classified as purposely falsifying information for benefit. At its worst, this involves practices providing false information on a patient’s medical record for financial gain. The OIG investigates and prosecutes practices that are found guilty of this type of behavior.

Best practices as outlined by these guidelines will help you keep yourself, your patients, your employees, and your practice safe.

At Apex EDI, we’re dedicated to making the medical claims process easier and helping medical practices get back to helping patients. We’re experts in medical claims processing policies and laws. We can help you better manage this confusing but important part of your practice.  We provide your practice with the tools and assistance necessary to cut down on claim denials and simplify medical claims filing.  Want to learn more? Request a demo today.

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Medical Claims Processing: How Are Medical Claims Processed?

File Folder Labeled as Claims in Multicolor Archive. Closeup View. Blurred Image. 3D Render.

Once medical services have been administered to a patient, payment needs to be requested from insurance through appropriate channels. These requests for payment are known as medical claims, and to the lay person, filing them may seem rather complicated. We’re hoping to demystify this process by breaking down the way medical claims are filed and paid.

Each service rendered to a patient has a designated code so that the payer will be able to reference them against codes and services the patient is eligible for. These codes along with insurance and patient information make up the bill that is sent on to a clearinghouse on its way to the patient’s insurance provider. Medical bills are often processed and submitted through online channels because it saves time and money, but hard copies are still available and occasionally used for this process.

This is where Apex EDI comes in. Forms are sent through clearinghouses like Apex EDI before being sent on to the insurance company so they can be scanned for errors and reformatted to comply with HIPAA and insurance company standards. Clearinghouses like ours are necessary because each insurance company has different standards, and doctors offices are responsible for submitting high volumes of claims to different insurers on a daily basis. Without a clearinghouse, the strain on the billing department of the office would be astronomical.

The doctor’s office chooses which clearinghouse it works with, and it’s important to select one that works with the insurance companies you work with, can work with the software you have available, and is reliable. Luckily, we at Apex EDI work with many different insurers as well as many different software programs. Visit our website or give us a quick call to see how we go above and beyond to serve all of your medical, dental, and vision claims needs. Choose Apex EDI to help you get your claims filed faster, get paid faster, and take the stress out of the claims filing process!

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Medical Claims Processing: How Do Medical Claims Work?

medical expensesThe medical claims industry is only a small part of the trillion dollar healthcare field. However, it is arguably one of the most important aspects for providers, as the medical claims process allows physicians and practitioners to maintain their clinics and businesses by receiving payment for their services. Let’s take a look at how medical claims actually work.

Services Rendered

The first step is for a patient to request services from a healthcare provider. The healthcare provider then grants services to the patient, be it in the form of a physical exam, diagnostic procedure, or any other billable service.

Each service is recognized in the medical industry with a unique code specific to that service. When the physician completes the patient report, the report will be submitted to medical claims with the appropriate medical codes for the services rendered.

Processing The Claims

The next step is to process the claims. This can be completed via traditional methods, such as fax or postal service. However, many practices are now implementing electronic claims processing, as it is significantly more cost effective, efficient, and secure than traditional methods.

The claims preparer examines the physician’s report on the patient. The preparer verifies that the claims codes are correct for the services that were rendered. The preparer creates the claim that will be sent to the insurance provider for that specific patient. The preparer might use a software such as Apex EDI for secure and efficient transfer of documents to the insurance company.

The claim is then processed by the insurance company.

Payment, Denial, and Appeals

Once a claim is processed, it is either approved or denied. A claim can be denied for a variety of reasons. The reason for denial could be as simple as the insurance company requesting more information before approval, or it could be that the service rendered is not an eligible service under the patient’s insurance coverage.

When a claim is approved, the insurance provider issues payment to the clinic or physician that submitted the medical claim. When a claim is denied, it may be resubmitted by the preparer, or the patient can appeal the denied claim to their insurance company. Typically a denied claim will require out of pocket payment from the insured patient in order to cover the cost of services rendered. However, a few exceptions have been made through lengthy appeals processes.

While medical claims billing might seem like a fairly straightforward process on the surface, there is a bit more to it than this article can provide. If you would like to know more about the medical claims billing process and how this aspect of your business can be streamlined with an EDI software, be sure to reach out to us by filling out the contact us form here. The professionals at Apex EDI will be happy to assist you with any questions you may have about improving your medical claims process.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

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2016 Medical Claims Processing: Who Determines the “Value” of Value-Based Payments?

With all the discussion around value-based payments and quality-incentive programs newly instituted by Medicare, one begs to question…who decides what’s quality? How do we know that what’s considered value to one is legitimately valuable to everyone?

Of course the answer to both questions is relative. In terms of medical care (and most everything else for that matter) it’s hard to define what “quality” really means. Our hats are off to CMS for at least attempting to define it and for trying to incentivize physicians, practitioners and facilities for value over volume. Though it seems like a nightmare in terms of submitting medical claims, the end goal is to increase the quality and efficiency of medical care, and that’s a win for everyone.

Here’s how they’re doing it…

The value-based payment program is comprised of two basic components. The first is the Quality and Resource Use Report (QRUR), which is basically a confidential report about both the cost and quality of care provided to Medicare patients. Secondly, there’s a Value-Based Payment Modifer (VBPM) or “score sheet” that adjusts payments up or down according to the results of the QRUR.

Thankfully, for those of us in medical claims, payment adjustments don’t happen in real time. It would be incredible if rates were charged according to the actual care given at any particular office visit or during a particular procedure, but we aren’t there quite yet. In 2015 CMS started applying the new score sheet to a select group of physicians, all based on performance data collected from their patients back in 2013. And that’s how things will continue. In 2016, the Value Modifier will be applied a specific group of physicians, based on performance in 2014.

For more information on value-based payments visit the CMS website at

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