One of the constant issues the healthcare industry has to deal with is medical claims processing. Every healthcare service provider grapples with many challenges related to the process, like inaccuracy, delays, denials, and compliance. It acts as an additional stress component on patients, medical staff, and administrators alike and can throw the healthcare facility’s financials off track while damaging its brand value. 

Numerous influences can cause claims to be rejected, including wrongful data entry, incompleteness, non-compliance to standards, wrong insurer, inexperienced coding, and billing staff. The solution to this problem is as diverse as the types and number of causes, and it may be difficult for your personnel to manage it alone. 

This is where outsourcing to a dedicated claims processing services agency helps, as you get the additional support and experience needed for accurate and timely claims management. Read on to learn about some measures you can take, in addition to outsourcing, to help your claims processing progress glitch-free.

Ways to Improve Your Medical Claims Processing

  • Maintain Patient Information Accuracy

Not keeping up with changes in a patient’s medical condition and updating the same in your records leads to multiple complications that will affect your claim processing. The claims form may end up containing already cured ailments or missing some new problems that may have led to the major health issue for the patient. 

In other cases, a patient may have sought a second opinion and followed that treatment. If that information isn’t entered in their EHR, then it could lead to a wrong diagnosis and the insurance company refusing to address that claim as a result. The solution is to schedule regular patient information updates on your server, with personal contact of the patient if necessary. The updates should also include changes to a patient’s other personal information that may be necessary for claims management, such as an address, job, marital status, etc. 

  • Regularly Train Your Staff

Your staff working on claims processing should undergo regular training, to be informed of relevant changes in the field. The typical changes are insurance providers’ terms and conditions, regional and international regulatory changes, internal company policy changes, and changes to operational procedures. 

You can enlist the help of external medical claim processing professionals to have this done for your staff. They will have the resources to update your claims processing department on everything they need to know to become more efficient and effective. 

  • Review Denials and Improve

Knowing what the problem was that caused a claim rejection is one of the fundamental steps you can take to improve your company’s overall claims processing procedure. Compile the list of rejected claims and the reason for the same given by the insurance companies from where they originated. 

Analyze those denials carefully to find out if the reasons given for them were legitimate or not. If yes, make a note of the same and inform the concerned claims processing staff member of their oversight. If you find a recurring theme with the rejections, look into any changes you need to make to the claims processing management system you’ve set up.

  • Apply Data Management Processes

Patient data is a heap that always gets bigger with time due to additional quantities that keep flowing. Then there are also administrative data that needs to be included as and when required for successful claims processing, and it is also one type of data that grows over time. This data addition is often riddled with issues like duplication, missing or incomplete data, lack of adherence to standards, and others. These issues guarantee that claims will get rejected if continued to that stage. 

You can solve this by running your medical data through a data management cycle. If you find this process complex, seek help from professional insurance claim processing service providers that also perform data management functions like standardization, deduplication, normalization, and cleansing. They can ensure that your medical data retains the quality needed for successful claims processing, especially if performed regularly. 

  • Review and Revise Insurer Contracts Regularly

The medical insurance companies that have onboarded you into their network can act as partners to your medical business, helping each other grow. However, this may not always be the case, and it could be that your relationship with a certain insurer is behind claims to them getting rejected. The fault could be from either end, so it helps to regularly review the contracts you’ve signed with insurance companies. 

If you find that there is some confusion over certain terms and conditions, which is causing the denials, then discuss the same and correct it quickly. Renegotiate old contracts, and if for some reason it goes beyond the point of no return, then go ahead and terminate the partnership with that company. Having insurers that can work with you according to set contractual conditions greatly reduces your claims denials. 

  • Maintain Clear and Continuous Communication

Sometimes, claims processing can go wrong because of communication issues between the various relevant stakeholders. Medical staff providing the first information for it can mention the wrong terms accidentally that are unrelated to their procedure. Those coding may not ask again, leading to a mistake in the pipeline and ultimately affecting the claims management process. 

You could also face communication issues with an outsourced claims processing services provider. One of the reasons for outsourcing is greater accuracy, but it won’t be the case without good communication between the two of you. And since this process is continuous and often remote, you should establish acceptable communication norms before signing the contract and adhere to them religiously. This includes how you’ll communicate, when, and who will liaise with the two. 

In other instances, there may be communication gaps between the administration and the insurer. This could happen due to many reasons, but the outcome is that claims can be denied, leading to more confusion. Therefore, you should ensure that there is constant and clear communication between all parties involved, including the patient. 

Having a liaison person to handle this between your institution and insurance companies goes a long way. You should also train your staff to respond to patient complaints and issues at once so that things are resolved at the source and don’t pass through to later stages of the claims processing pipeline. 

  • Automate the Process

The world is moving increasingly toward the automation of tasks, with every industry looking to automate everything it can. The healthcare industry is no different, with even complex procedures like surgery being automated to some extent. This is because automation is economical and, more importantly, accurate. Medical claim processing can be improved greatly by these two aspects of automation. 

You could have a custom AI developed for the purpose by hiring a dedicated agency. The advantage of doing this is that it can be tailored to your needs, specifically using your medical data. Or you could go with some of the standard options available in the market. Just make sure that it fits the criteria you are looking for regarding your claims processing management, such as its ability to integrate with existing software. 


Every new day brings new challenges for everyone involved in the healthcare industry. It also brings new opportunities for growth and better treatment options for patients. Accurate insurance claim processing by an expert acts as the catalyst to bolster this growth potential. It enables you to seize the opportunities presented with the steady inflow of revenue that’s necessary for the right investments, along with the maintenance of brand value in the market.

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