Healthcare Claims Processing

Written by Kimberly Clark
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Because of the variety of services and numerous levels of coverage offered by many insurance companies, processing healthcare claims has become quite an intricate task. In addition, there are several different sets of medical codes used by physicians to indicate such things as the diagnosis and the selected treatment options. To ensure proper payment, all of these variables must be taken into account when processing a claim.

The matter is further complicated by ever-changing federal and local regulatory requirements. For instance, the regulations impose specific time limits on health insurance companies during which they must pay or deny submitted claims. If the claims are not paid or denied within the specified time frame, the insurance company can incur stiff financial penalties.

With all the complexity surrounding healthcare claims processing, the healthcare payer has to be certain that whomever is handling their claims knows exactly what they are doing. If information is missing or incorrect, payment on the claim might be delayed or denied. Inefficient healthcare claims processing drives down customer satisfaction and only serves to frustrate the health care plan members.

Automating Healthcare Claims Processing

In an effort to reduce their overhead costs, insurance companies are very interested in automating the healthcare claims process. Researchers estimate that the average cost of manually processing healthcare claims is about $10 per claim, whereas automating the process would cut the cost to less than $1 per claim. Automating healthcare claims processing also significantly reduces the time it takes to get the claim approved and subsequently paid.


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