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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.

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Top Reasons to Use A Medical Billing Company: Cost Savings and Consistency

As a healthcare provider, you wear a lot of hats. Medical billing might be one of them. Let’s discuss why it will be beneficial for your healthcare practice to consider outsourcing billing practices to a professional medical billing company.041019-N-5821P-019

Cost Savings

The cost savings associated with using a medical billing company as opposed to completing billing in house is significant. A study completed by Physician’s New found that the typical cost to process medical billing procedures in house is approximately $118,000 per year. The cost of billing department costs per year when the practice of medical billing is outsourced? $4,000.

That’s less than 1/30 of what your healthcare practice would pay if you continued to process medical billing in house. In addition to significant billing department costs, your practice will also be able to collect up to 5-15% more of billings processed. While that might not seem like much now, it can add up into a significant profit over the course of a fiscal year.

Consistency

Another reason to use a medical billing company is the consistency you will experience. Consistency in the form of denied claims appeals, staffing requirements, and various other processing practices for medical claims and billing procedures.

The professionals who are employed by the medical billing company you choose to outsource your billing procedures to are experts in their field. They know exactly what needs to be completed in order to process claims quickly and efficiently. Not only will they be able to uphold industry standards, the medical billing company will be able to efficiently adhere to changing standards and legislation in the field.

Apex EDI is a great method of streamlining your process with medical billing. In order to ensure that medical claims are billed properly and efficiently, consider utilizing the software integration behind Apex EDI. Apex OneTouch, the desktop app, integrates seamlessly with over 30 practice management softwares to ensure fast, efficient, and accurate billing for you and your medical billing provider.

For more information, visit our products page.

https://physiciansnews.com/2010/06/17/should-your-practice-outsource-medical-billing/
http://www.carecloud.com/blog/in-house-vs-outsourced-medical-billing-pros-and-cons/
http://www.mbahealthgroup.com/2015/03/8-benefits-outsourcing-medical-billing/

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Why Use EDI in Healthcare?

As the digital world continues to advance, we are privileged to use various software and technologies that make our jobs easier. Once such technology is electronic data integration (EDI). EDI allows for improved healthcare claims processing, including better security and efficiency for patients and healthcare providers.Patient and medical staff

Security

EDI allows for improved security and privacy measures for healthcare claims processing. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 protects patient’s privacy and provides boundaries as to whom medical records can be released to. EDI minimizes the possibility of information over sharing when it comes to medical records and health care claims submissions.

For example, traditional information sharing through paper claims mailed through the postal system or information emailed to an individual increased the chances that more individuals than necessary came into contact with the private information. While these individuals may have clearance to handle this information, it is an inefficient and insecure method of information sharing.

EDI, on the other hand, specifically integrates with a health management system within your healthcare practice to minimize information handling and claims processing. Instead of passing patient information from person to person (or email to email), the EDI software passes the documents through a securely integrated system that is based on specifically coded transactions.

These transactions can only be viewed and processed by another EDI system that can read the agreed upon standard formatting of these coded documents. This ability to share documents and information between EDI softwares that only accept certain codes increases the security of patient information and healthcare claims.

Efficiency

Efficiency is another great reason to use EDI in healthcare practices. EDI significantly decreases the amount of time it takes to submit and process a claim. Not only will most EDI’s help you to identify potential mistakes within the claim to be submitted, it will also assist in the processing by providing real time feedback about the claims submission.

Efficiency in processing allows for healthcare claims to be processed faster, meaning healthcare providers can get paid for services rendered more quickly through an EDI software.

Though security and efficiency are important aspects to any software within a healthcare practice, it is critically important within an EDI. For more information about plans and pricing of Apex EDI software, reach out to us on our Contact Us page. Security and efficiency are of utmost importance to our professionals at Apex EDI. We will be happy to assist you in incorporating a secure and efficient medical claims software into your practice.

http://www.edibasics.com/what-is-edi/
http://www.edibasics.com/edi-resources/document-standards/hipaa/

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Reasons To Do EDI Claims: Efficiency, ROI, and Expediency

Electronic Data Integration (EDI) has come to the forefront of information transfer in recent years. Exactly what is EDI, how can it be used for medical professionals, and what are the primary benefits of using EDI? Let’s examine these queries further.

EDI Defined

As we have already determined, EDI stands for electronic data integration. EDI the exchange of documents in a standard format from computer to computer. The difference between traditional methods of document exchange, such as a mail, email, or fax, is that EDI eliminates a lot of the processes of the exchange.

For example, traditionally faxed documents involve one individual preparing the documents, the fax machine sending the documents, the recipient receives the documents, the recipient processes the documents, then the recipient sends the documents back through the fax machine to the original sender, and then the process is repeated in order to properly process the documents.

This 5+ step process is inefficient, desperately slow, and minimizes the opportunity for profitable practices. EDI helps to eliminate these inefficient processes, and provides maximum output for profitable earning activities through efficient document exchange.

Use in the Medical Field

CLAIMS CONCEPT man hand on table Business, coffee, Split tone

For medical professionals, this is a wonderful invention. EDI allows the expedient processing of medical claims, patient data transfers, and information requests on medical history. EDI can be used in multiple areas of medical expertise, including but not limited to traditional medical practices, dental practices, chiropractic care, mental health counseling, and beyond.

Apex EDI is the premier EDI software that can be integrated into existing practice management software. EDI provides a host of benefits for medical providers, which we will discuss in the next subheading.

 


Benefits of Using EDI for Medical Claims

While the benefits of using EDI are vast for medical claims billings, a few stand out in our mind as invaluable. They include efficiency, returns on investment, and expediency.

Efficiency

EDI increases medical claims billing efficiency by eliminating repetitive tasks and expediting the accuracy of documents that allow your staff to improve production and processing of medical claims.

ROI

ROI - Return on investment
EDI return on investment (ROI) is a substantial benefit for medical claims billing providers. Elimination of
paper processing such as printing, postage, and illegible faxes allows for a cost savings of up to 35%.

Expediency

The efficiency of EDI also allows for faster claims processing. Exchange transactions take place in minutes instead of hours or days required by email or traditional postal services.

Overall, EDI systems are a phenomenal method of improving efficiency, expediency, and profitable business practices for medical claims billing. Apex EDI allows for all of the benefits and more. For additional reasons to use Apex EDI for your medical claims billing practices, visit our Contact Us page in order to receive more information.

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Things You Should Know About Submitting Dental Claims

While medical claims billing can be complicated, submitting dental claims is an entirely different beast. Before you submit any dental claims, be sure to educate yourself and your practitioners about the do’s and don’ts of dental claims billing.

Paper or E-File?

Do you stdentist 1ill submit claims for your dental practice through snail mail? It might be in your best interest to consider updating your practice to include electronic filing. Electronic filing processes claims more quickly and efficiently than traditional postal service submission. Even if you currently incorporate electronic filing at your practice, some payers may still require paper submissions. In this case, be sure to keep an electronic record of all dental claims submissions to payers who require paper claims.

If you’re interested in incorporating electronic filing into your dental practice, check out our Dental Claims page for more information about seamlessly integrating this software with your existing dental practice management software.

Are X-Rays Needed?

050803-N-1126D-004 Jacksonville, Fla. (Aug. 3, 2005) - Dental Technician 3rd Class Jose Sanchez prepares a patient for dental X-Rays at the Naval Hospital on board Naval Air Station Jacksonville, Fla. U.S. Navy photo by Photographer's Mate 3rd Class Clarck Desire (RELEASED)

As a dental practitioner, you know that some claims require x-rays in order to be properly processed. Common claims that require x-rays include restorative practices such as crowns, implant supported prosthetics, and fixed partial denture retainers, to name a few.

With Apex EDI, you’ll know exactly which claims will require x-rays for proper submission and processing. Apex OneTouch, the desktop application, will notify your claims professionals of failed claim submissions due to missing items or mistyped information.

Best Practices for Patient Education

Before submitting any dental claims, it is important to educate the patient about the claims process. Your practice may differ from another dental practice in claims submission. It is important to educate the patient about the difference between in- and out-of-network providers, as well as providers that are not accepted at your dental practice, as well as the typical process of claims submission.

This may include the length of time required to process a claim, and how your practice will contact the patient if there is any out-of-pocket expenses required on their part as per their dental insurance provider. By educating the patient about your dental clinic’s best practices, you are hopefully preventing any miscommunication or misleading practices that could cause patient dissatisfaction or overdue accounts.

In order to put your best foot forward in your dental practice, be sure to check out our Dental Claims page for more information about how we at Apex EDI can simplify dental claims submissions for you.

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