3 Critical Challenges That Medical Claims Processing Companies Will Help You to Deal With

Medical claims processing is critical to maintain the fiscal health of clinical organizations. It is constituted by five key steps which are scheduling appointment, patient visit, submission of claims, claims adjudication, and claims approval.

The entire process involves multiple touchpoints that manually process massive amount of information. Such manual processing heightens the chances of data entry error in the final claims file. An error as minute as adding an extra letter to a patient’s name can result in outright claim denials.

Medical claims processing companies have the right set of expertise and experience to help healthcare organizations maneuver all the simple to complex challenges during claims processing.

In this article, we will highlight the three most critical challenges dealt by medical claims companies every day.

Massive Data Amount

There’s a lot of data involved to review, adjudicate, and finalize a claims file. This data includes diagnosis report, lab test results, patient information, insurance carrier details, SSN, and others.

The problem arises when such a huge amount of diverse data is processed manually. It significantly delays the process as well as peaks the chances of claims processors overlook fine details. Such fine details can make a huge impact in the final claims file.

Third-party experts leverage advanced billing software that create workflows. These workflows automate the task of gathering documents from multiple touchpoints and analyze through it to file claims. The tools are programmed by rules to find errors like incorrect codes, inconsistent patient information, and others. Automation of these repetitive tasks expedites the process of claim filing despite the involvement of a large amount of data.

Slow Claim Resolution TAT

Erroneous code entry is a significant reason for a slow processing TAT. Medical codebooks undergo regular changes. It becomes next to impossible for administrative staff to regularly track such changes as they are already stretched between multiple non-core medical tasks.

The lack of knowledge on coding updates results in erroneous code entries. This requires staffs to back track to the process, find and enter the right code, get it approved from other departments, and disburse the file. The entire process backtracking delays the entire process.

Medical claims processing companies ensure that their experts are constantly on track with the medical codebook changes. They are trained to immediately incorporate the necessary changes in their services as per new diagnostic codes. This eliminates the chances of coding errors, thereby improving claims resolution TAT.

They leverage analytic solutions to provide real-time reporting on ongoing claim processing status. This allows healthcare organizations to have a complete visibility on any settlement delays and act on those swiftly.

Deployment of Legal Technologies

There are instances when healthcare firms use claims processing technologies that are not vetted by regulatory authorities such as Health Insurance Portability and Accountability Act of 1996 (HIPAA). This endangers patient information and exposes it to potential hackers.

Outsourcing companies follow rigid compliance protocols that include using HIPAA certified software. They associate utmost importance to safeguarding patient data that is critical in the consumer-centric healthcare.


The entire purpose of making medical claims processing more efficient is defeated if enterprises fail to partner with the right outsourcing company. To ensure this, they must consider factors like level of technology adoption, expertise of staffs in the claims processing domain, years of experience in this field, regulatory compliance, and others.

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