Health insurance companies providing payment for medical services
Health insurance companies provide the majority of the payment for medical services that clinics and physicians deliver. After the care has been delivered, the medical record is reviewed for completeness, codes are applied, and the billing office submits the claim to the insurance company or other third-party payer for payment. There are several steps to take when submitting a claim form to the insurance company for reimbursement. The result of a clean claim is proper reimbursement for the services the facility has provided.
Discuss the following:
- What does it mean to submit a clean claim?
- List all of the information that is important before the claim can be submitted.
- Discuss some of the reasons why a claim may be rejected.
- State various reasons for the importance of a clean claim submission.
- Address the consequences of not submitting a clean claim.
Financial Procedures in a Healthcare Organization
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Financial Procedures in a Healthcare Organization
Health Insurance Companies Providing Payment for Medical Services
As the healthcare industry is swiftly changing, healthcare organizations must apply effective financial procedures to ensure long-term continualness. These procedures are the policies and practices controlling an organization’s financial operations, including budgeting, accounting, revenue cycle management, and financial disclosure (Zietlow et al., 2018). In the healthcare industry, the procedures are essential in managing costs, revenue optimization, and acting according to complex regulatory requirements. This essay will explore the meaning of submitting a clean claim, the essential information before submitting a claim, the reasons why a claim may be rejected, the importance of a clean claim, and the consequences of not submitting a clean claim.
Submitting a Clean Claim Definition
Submitting a clean claim may symbolize that a healthcare provider has correctly and completely filled out a claim form and submitted it to the relevant insurance institution with no errors, omissions, or inconsistencies. A clean claim entails all the relevant information, such as patient demographics, diagnosis codes, treatment codes, and provider information (Thesmar et al., 2019). By submitting a clean claim, the provider minimizes the probability of the claim being denied or delayed due to errors resulting in additional work, hamper reimbursement, and improved cost for both the provider and the patient. A clean claim also confirms that the insurance institution contains the relevant details to promptly process the claim and pay the provider.
The Relevant Information Before the Submission of a Claim
Before submitting a claim, various essential details have to be gathered to confirm a successful claim. The information about the incident causing the claim must be collected, which involves the date, time, and location of the incident (de Bruijn et al., 2019). In addition, the witnesses or other parties involved in the incident should be identified, and their contact details obtained. It is essential to stockpile all applicable documentation relating to the incident, including reports from the police, medical reports, and any other applicable paperwork. The documentation is supposed to be inspected and organized in a clear and potted manner, indicating critical information supporting the claim. For the incident information and supporting documentation, it is essential to clearly comprehend the insurance policy to which the claim is being filed (Ayuso et al., 2019). It includes comprehending the policy coverage limits, deductibles, and any restrictions influencing the claim. It is vital to know the claims process and requirements for submitting the claim, entailing any deadlines or other time-sensitive requirements. An apparent comprehension of the claim process helps ensure that the claim is submitted on time and contains all necessary processing requirements.
Reasons why a Claim may be Rejected
Various reasons can make an insurance claim to be rejected by an insurance company. The first reason the claim may be rejected is that the claim is not covered under the policy (Bourova et al., 2022). This brings the necessity of policyholders thoroughly reading and comprehending the terms and conditions of their policy before developing a claim. The second reason a claim may be rejected is that the claim not meeting the needed criteria or lacks sufficient evidence verifying the legitimacy of the claim. When no sufficient evidence or the claim is unclear, this may lead to the rejection of the claim. The third reason for rejecting the claim is that the claim is fraudulent (Tumminello et al., 2022). Insurance institutions contain meticulous fraud detection systems in place, and if the claim is suspected to be fraudulent, it may be rejected. In case of a delay in the submission of the claim may lead to the claim being rejected, as insurance policies have a specific timeframe within which a claim must be submitted. It is vital to submit claims immediately after the incident has occurred.
Reasons for the Importance of a Clean Claim Submission
It is vital to submit a clean claim for healthcare providers and insurance companies to process claims and ensure timely reimbursement effectively. One crucial reason for the importance of a clean claim submission is that it minimizes the chances of rejection (Johnson et al., 2021). Healthcare providers may lose revenue due to a rejected claim resulting from the claim not being submitted accurately and completely. Submitting a clean claim ensures that all the needed details are accurately apprehended and organized, improving the claims process’s efficiency and minimizing errors and avoiding duplicate claims. Submitting a clean claim enhances communication between insurance institutions and healthcare providers. Clear and incisive communication ensures that all parties comprehend the information of the claim and can resolve any issue first. Submitting a clean claim helps comply with regulatory needs like HIPAA, which safeguards the privacy and security of patient information. Submitting a clean claim minimizes denials and rejections, improves effectiveness, amplifies communication, and ensures regulatory compliance.
The Consequences of Not Submitting a Clean Claim
Failure to submit a clean claim may have significant consequences for healthcare providers and the patient. If a claim is not clean, insurance companies may reject or deny it, leading to detained payment and escalated administrative costs for providers (Cuevas, 2018). This may also affect the patient negatively when their claims are not processed on time, resulting in unexpected medical bills and financial hardship. In addition, providers may encounter vandalism to their fame and reliability in case of a pattern of submitting inaccurate claims leading to decreased patient trust and poor revenue. Submitting a clean claim for providers and patients is vital, ensuring accurate payment for healthcare services.
Conclusion
Financial procedures are essential in healthcare organizations, and a clean claim submission is a radical aspect of the billing process. A clean claim contains the relevant details needed for processing and payments. It is essential to ensure that the relevant patient details like demographics and insurance information are accurate before submitting a claim. Failure to obey the requirements can lead to the claim being rejected. It is essential to submit a clean claim as it can lead to quick payments, minimized administrative costs, and improved patient satisfaction, while an unclean claim can lead to delayed payments, increased costs, and patient dissatisfaction. Healthcare organizations must grade the submission of clean clam to amend the revenue cycle management.
References
Ayuso, M., Guillen, M., & Nielsen, J. P. (2019). Improving automobile insurance ratemaking using telematics: incorporating mileage and driver behaviour data. Transportation, 46, 735-752. https://doi.org/10.1007/s11116-018-9890-7
Bourova, E., Ramsay, I., & Ali, P. (2022). The arduous work of making claims in the wake of disaster: Perspectives from policyholders. Geographical Research, 60(4), 534-548. https://doi.org/10.1111/1745-5871.12553
Cuevas, C. A. R. (2018). Discrete-event Simulation of an Improved Medical Billing System Using Lean and Point of Sale (POS) Concepts (Doctoral dissertation, Universidad Politecnica Puerto Rico (Puerto Rico)).
de Bruijn, J. A., de Moel, H., Jongman, B., de Ruiter, M. C., Wagemaker, J., & Aerts, J. C. (2019). A global database of historic and real-time flood events based on social media. Scientific data, 6(1), 311. https://doi.org/10.1038/s41597-019-0326-9
Johnson, M., Albizri, A., & Harfouche, A. (2021). Responsible artificial intelligence in healthcare: Predicting and preventing insurance claim denials for economic and social wellbeing. Information Systems Frontiers, 1-17. https://doi.org/10.1007/s10796-021-10137-5
Stowell, N. F., Schmidt, M., & Wadlinger, N. (2018). Healthcare fraud under the microscope: improving its prevention. Journal of Financial Crime, 25(4), 1039-1061. https://doi.org/10.1108/JFC-05-2017-0041
Thesmar, D., Sraer, D., Pinheiro, L., Dadson, N., Veliche, R., & Greenberg, P. (2019). Combining the power of artificial intelligence with the richness of healthcare claims data: Opportunities and challenges. Pharmacol Economics, 37, 745-752. https://doi.org/10.1007/s40273-019-00777-6
Tumminello, M., Consiglio, A., Vassallo, P., Cesari, R., & Farabullini, F. (2022). Insurance fraud detection: A statistically validated network approach. Journal of Risk and Insurance. https://doi.org/10.1111/jori.12415
Zietlow, J., Hankin, J. A., Seidner, A., & O’Brien, T. (2018). Financial management for nonprofit organizations: Policies and practices. John Wiley & Sons.
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