5 Ways Technology Can Improve Claims Adjudication Process

Claims adjudication is an integral component of healthcare administration that engages multiple stakeholders - providers, payers and patients. But its process can be extremely complex: even minor errors can result in claim denials, delayed payments or revenue losses. In this blog post we'll examine its complexities while looking at its key components as well as solutions that could make claims adjudication more efficient. 

What is Claims Adjudication?

It is the process of evaluating and processing claims submitted by healthcare providers to health plans for payment. It requires a thorough understanding of healthcare billing codes, policy specifications, and patient information to ensure accuracy and compliance with regulatory guidelines.  

In this process, health plans and other payers review healthcare claims submitted by providers and determine whether to pay the claim in full, pay partially, or deny the claim altogether.   

It is the responsibility of healthcare providers to verify a patient's enrollment and coverage status and determine whether referrals or prior authorizations are required before providing care. Failure to do so can lead to delays in processing and loss of revenue for providers.  

To ensure that a claim is reimbursed, it must meet the following criteria: 

• Providers must verify patient coverage and authorization requirements. 

• Claims must include accurate patient and service details. 

• All documentation must meet payer and regulatory requirements. 

Also, read 6 Ways Technology Can Enable Accurate Claims Adjudication 

3 Practical Steps to Streamline the Claims Process 

1. Verify Patient Eligibility  

Before providing any medical services or treatments, it is essential to confirm that the patient has valid insurance coverage and that the services provided are eligible for reimbursement. This is important to prevent potential denials or delays in the claims process that can lead to financial losses for both the provider and the patient.  

To verify patient eligibility, healthcare providers can use the health plan’s portal to gather accurate and up-to-date information about the patient's insurance coverage. This may involve checking the patient's insurance card or contacting the insurance company directly to confirm coverage details. It is important to verify not only the type of insurance but also the patient's specific benefits, such as deductibles, copays, and coverage limits, as these can vary depending on the plan.  

Many Electronic Health Record (EHR) systems now offer real-time eligibility verification directly integrated with payer systems. This ensures providers get instant confirmation of coverage details and benefit specifics, streamlining the process for both patient and provider. 

Also, read Essential Steps to Improve Claims Adjudication 

2. Submit Clean Claims 

A claim is considered clean when it is submitted within a specified timeframe and contains all necessary information required by the health plan for reimbursement. To submit clean claims, healthcare providers must ensure that all patient information is accurate and complete. This includes verifying the patient's name, date of birth, insurance information, and other relevant details. It also involves attaching any necessary documentation, such as medical records, lab results, or referral forms. It is important to make sure that all the documents submitted are legible, up-to-date, and relevant to the services provided.  

In order to avoid claim denials or delays, healthcare providers must submit clean claims on the first attempt as any errors in patient information may require additional administrative efforts to correct.   

Mirra’s Claims Management Solution can automatically flag missing or incorrect information before submission. This solution integrates directly with payer systems, reducing the chance of human error. 

3. Monitor Claim Status 

Monitoring the status of claims and following up with health plan regularly is a crucial step in the claims process. This helps providers identify any issues or delays and address them in a timely manner to prevent them from negatively affecting revenue and patient care.  

Claims may be delayed or denied for various reasons, including errors in patient information or coding, missing documentation, or issues with insurance coverage. By monitoring the status of claims and following up with health plan regularly, healthcare providers can ensure that claims are processed on time. This involves checking the status of claims and tracking any denials or delays in payment. It also involves contacting health plans to follow up on any outstanding claims and resolving any discrepancies as soon as possible.   
   
Additionally, it is important to ensure that staff members are familiar with common errors that can occur during the claims process. They should be trained accordingly to identify these errors so as to avoid submitting inaccurate or incomplete claims.  

Mirra’s Claim Adjudication Solution has a claim tracking dashboard that offers real-time status updates for each claim. Providers can set up alerts when a claim is denied, approved, or under review, allowing for rapid follow-up. 

According to an estimate, almost 20% of all claims are denied^*, and a significant percentage of returned claims are never resubmitted. Given the high rate of denial, it is important for healthcare providers to adopt certain tools and technology to eliminate the risk of claim denial. Utilizing electronic tools or claims management software can help streamline processes and improve efficiency.   

Read more: 5 Solutions To Bring Down Your Claims Denial Rate 

5 Benefits of Utilizing Technology for Claims Adjudication Process 

Advanced technological features can help make the claims process more efficient in following ways:  

• Automates tasks like claims submission, claims follow-up and claims tracking.  

• Ensures that patient information is accurate  

• Eliminates delays associated with paper-based claims submission  

• Provides updates in real-time for the status of claims  

• Integrates easily with billing and scheduling systems.  

Overall, the use of technology can aid healthcare providers in improving their bottom line by decreasing administrative costs, increasing revenue, and ultimately enhancing patient care management systems.    

Why Choose Mirra Healthcare’s Claims Adjudication Solution?

Mirra Healthcare’s technological solution for claims processing is ideal for various types of plans including HMO, PPO, dental, vision, etc. Their high adjudication rate can improve the quality of claims processing and offer other benefits, such as the following:  
 
1. Automation for Speed and Accuracy 

 Mirra healthcare’s solutions, such as ClaimsLite® (for paper claims) and ClaiMaster® (for EDI claims), ensure fast and consistent claims handling. With a high auto-adjudication rate, our platform improves both the timeliness and quality of claims processing. 

Also, read Revolutionize Claims Adjudication Process with Automation 

2. Smart Integration with Third-Party Systems 

Fragmented systems often create operational silos and inefficiencies. That’s why Mirra’s claims adjudication solution is designed for seamless integration with third-party platforms and gateways. Whether you’re working with HMO, PPO, Dental, Vision, or other plans, our flexible configuration rules allow benefits to be processed effortlessly. This interoperability minimizes IT overhead, simplifies onboarding, and ensures scalability across diverse plan types without disrupting your existing workflows. 

Also, read Top Benefits of Medical Claims Integration 

3. Real-Time Dashboards and Global Search 

Mirra’s interactive dashboards categorize claims by type (Professional, Institutional, Dental) and offer a global search function that lets users instantly retrieve claims using data like NPI, claim number, or patient ID. This enhances decision-making and shortens the resolution cycle. 

4. Built-In Fraud, Waste & Abuse (FWA) Detection 

Detecting anomalies early is critical to avoiding revenue loss. Mirra’s claims adjudication solution comes equipped with over 40 million edits, including CMS guidelines, to automatically flag suspicious or non-compliant claims. High-dollar reviews and built-in quality checks proactively identify potential instances of fraud, waste, or abuse.  

5. Comprehensive Queue & File Management 

Efficient claims processing requires organized workflows and centralized file access. Mirra's Claims Adjudication Solution includes queue-based processing that categorizes claim progress and prioritizes tasks based on pending, approved, or paid claims. Meanwhile, the file management system ensures all related documents, encounter files, and uploads are readily accessible and easy to manage. This results in reduced backlog and streamlines claims adjudication cycle. 

Conclusion

We've explored the five key benefits of utilizing technology for claims adjudication process which are automation of routine tasks, improved data accuracy, elimination of paper-based delays, real-time status updates, and seamless system integration. These technological advancements allow healthcare organizations to focus more on patient care while ensuring maximum revenue recovery. 

By implementing Mirra Healthcare’s claims adjudication solution, providers can significantly reduce claim denials, accelerate reimbursement cycles, and minimize operational tasks. 

Don't let outdated processes continue to impact your bottom line. Visit Mirra Health Care to explore their Medicare Advantage In a Box solution and claims adjudication solution. Learn how it can help enhance patient care and boost the financial health of your medical practice. Contact us for more information. 

Reference 

https://journal.ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution