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What is Claims Adjudication?

After a medical claim is submitted, the insurance company determines their financial responsibility for the payment to the provider. This process is referred to as claims adjudication. The insurance company can decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider.

When an insurance companyAdobeStock_94630507 decides to reduce a payment to the provider, they have determined that the billed service level isn’t appropriate for the diagnosis or procedure codes. Therefore, it is important to ensure that all claims submitted for payment are coded accurately.

As soon as an insurance company receives a medical claim, they begin a thorough review. Sometimes even small errors such as a misspelled patient name may cause a claim to be rejected. This delay prevents you from receiving payment while corrections are made.

When claims are submitted electronically, the software can help prevent errors such as incomplete or inaccurate information before it is submitted for payment. This helps increase the speed at which you can be reimbursed for services.

Once claims are received by the insurance company, the review continues with detailed analysis of the insurance policy. Some claims are even checked manually by medical examiners who examine medical documentation to determine if procedures are medically necessary.

When the claim has passed through the review process, it can finally be paid. Having a clearinghouse partner, like Apex EDI, to prevent errors in claim submissions helps you get paid quickly. Contact Apex EDI to watch a free demonstration of our software today.

Posted in: medical billing clearinghouse, Medical Claims, Uncategorized

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What Does the Medical Claims Process Look Like?

The medical claims process begins when the patient goes to the healthcare provider for any service, from refilling a prescription to major surgery. The patient is responsible for paying the insurance deductible after the visit and providing insurance information to the healthcare provider.

Health insurance claim form with glasses

Typically, front office staff begin the claims process with a pre-registration form. Information such as patient name, birth date, and insurance policy number is gathered. Keeping current medical records helps expedite the billing and patient check in process. It can also eliminate errors that may occur. For example, if the patient forgets to bring insurance information with them.

Once the patient provides insurance information, the office must confirm the medical services that are covered under the patient’s insurance policy and what medical conditions the insurance provider requires in order to justify financial payment.

When the patient receives service, it is important for the provider to record all medical services received. To bill the insurance company, each service must be coded accurately. The bill must also be compliant with legal requirements set forth in the Health Insurance Portability and Accountability Act (HIPAA).

It’s imperative to confirm that fees are charged accurately and that every code submitted is billable before it is sent to the insurance company. This insurance claim provides the payer with important information about the diagnosis, procedures, and the charges. An accurate insurance claim ensures that you are reimbursed in a timely manner.  

Apex EDI acts as a clearinghouse and liaison between healthcare providers and insurers. We can help format claims and submit the claim to the insurance company. Accurate, timely claims help you get paid faster. Interested in our help? Contact us, at Apex EDI, to watch a free demonstration of our medical claims software today.

Posted in: medical billing clearinghouse, Medical Claims

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Will Medical Claims Software Help My Practice? What Should I Look For?

Concentrated female doctor using computer at desk in medical office

Implementing a medical claims software is an easy way to see an immediate increase in revenue for your health care practice with a minimal investment. The software allows your staff to focus their time on what’s really important, the care of patients, rather than tracking and submitting medical claims. There are a number of features to look for in a good medical claims software.

First, you will want to make sure the software partner you select offers the best customer support possible. Look for a company that can offer the assistance of a well-trained, knowledgeable support staff to address any technology questions your staff may have. At Apex EDI, we are committed to providing the fastest, most personal, and most capable customer service and technical support in the electronic claims processing industry.

Then you will want to be certain the software is equipped to keep up with ongoing changes in the healthcare industry. The system must have the highest level of data security to remain in compliance with patient privacy regulations. You will also want superior coding and reporting functions that will increase the efficiency of your practice.

The American Medical Association reported that the average practice can cut medical claim submission costs by up to 55% by simply making the transition to an automated medical claims software. At Apex EDI, we want to help you reduce your costs and increase the accuracy of your claim submissions. Our software offers the most complete range of features in the industry. Contact us to watch a free demonstration of our software today.

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Why You Should Use Vision Billing Software

File Folder Labeled as Claims.At Apex EDI, our goal is to help you create a better workflow within your clinic and simplify the billing process, so you can focus on patient care. The  has always been a source of frustration for office staff. Billing and coding errors can also be devastating to your practice.

An integrated software system means that claims can be transmitted directly from your system. This eliminates a tedious responsibility of entering patient data into more than one system or faxing information to other companies. Ultimately it saves staff a significant amount of time and energy. It also saves paper and money.

Any time information is re-entered, copied, scanned, or faxed it increases the potential for human error. Misspelled patient names, unreadable information, or incorrect billing codes can result in denied claims. A software, like Apex EDI, eliminates this risk. When insurance companies receive error free claims, this means you are reimbursed faster every time for every patient. It allows the front office staff to focus their attention on greeting patients with care.

  

Our integrated system also allows you to easily attach patient documentation such as progress notes. There’s no need to search for and organize this information when submitting claims. It’s literally at your fingertips. It also gives you the ability to easily view reports to help manage your practice.

You’ll be able to access financial data such as revenue per visit, patient cancellations, and accounts receivable. This powerful information allows your team to reach higher levels of productivity.

Contact Apex EDI to learn more and request a free demonstration of our software today.

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Tips for Negotiating Claims with Insurance Companies

Negotiating an insurance claim

When healthcare providers and staff understand how to communicate with insurance companies, it can make medical billing and claims processing much easier. It’s not uncommon for an insurance adjuster to offer an initial settlement at a lower amount than you requested. Negotiating a final settlement can have a positive impact on your business.

It’s imperative to first determine what you believe your claim is worth and decide on a minimum settlement figure that you will accept. When you receive an offer that seems low, ask the insurance company to give you specific reasons why the offer is so low. Then follow up by writing a brief letter responding to each of the facts the insurance company mentioned.

It’s also helpful to mention emotional suffering the patient

experienced in your letter and conversations. There is no way to put a dollar value on life changing health issues and they can be a powerful way to influence a higher settlement. For example, you may want to include a photo of a severe injury and mention the impact on the patient’s ability to perform daily work or life routines.  

During the negotiation process, if the insurance company provides some facts that you had not considered, you may have to lower your figure a bit. Typically within two to three conversations you can agree to a settlement amount somewhere in between your desired payment and their offer. Once you reach an agreement, follow up with a short letter confirming the amount offered.

Remember it’s not advisable to take the first offer you receive from an insurance carrier, even if it is reasonable. It always helps to make a counteroffer that is fair. During a phone call with the insurance adjuster, you can discuss the strengths and weaknesses of your claim. With a little bargaining, you can often get to an agreement that is better than the initial offer and satisfies both of you.  

Submitting medical claims and negotiating settlements with insurance companies is a process that Apex EDI knows and can help you with. We want to make sure your practice thrives and that you receive the maximum payment you are entitled to. Contact Apex EDI to request a free demonstration of our medical billing software today.

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