We gain information regarding a member's insurance coverage. It helps us to reduce patient financial surprises, increase revenue for the provider, and can be used to address appeals.
The claims submission process involves reviewing the claim data before submitting the claims to insurance. We use the functionality in the practice management systems to verify the data integrity. We identify and correct the denials and work edits prior to onward submission to insurance companies.
We engage in the process on behalf of the providers to get reimbursed for services they provide to patients.
In Healthcare Data Management (HDM), we manage the lifecycle of health data. We create, store, organize, process, archive, and destroy Data. In addition, data is also protected to maintain a strict level of confidentiality, and integrity and is handled only by the assigned people.
"Medical necessity" is a term used by insurance companies to determine whether they will cover a particular service. Even clinical approval is not always a guarantee of payment, as other administrative processes such as coding, timeliness, and network rules may interfere with reimbursement. There could be many reasons for the insurance to deny the authorization including failure to meet medical necessity criteria, insufficient clinical information, or not submitting information within the required timeframe. These are common reasons why providers may dislike the insurance process, as it can limit their clinical judgment and autonomy. However, we can work on these areas to ensure that claims are reimbursed.