Imagine, you just started your dream office manager job with a new provider and the time to submit a claim has finally come. You’re pretty sure that there’s nothing wrong with what you submitted to a payer. The information you gave, the time frame in which you submitted was correct, and so you expect a relatively quick return.

A few days go by and you still haven’t heard back about the status of that claim. You notice that there hasn’t been any activity in the practice’s bank account, so you’re getting nervous.

What happened to the claim? Why is there such a delay in the processing? Is there something that needs fixed? Maybe there’s a best tip you need to keep in mind so that you don’t run into this issue again?

You’re not alone in this! Most healthcare providers will usually agree that the journey to a timely claim filing can be tedious and frustrating.

But, taking the time to understand and streamline this process is very important, but can feel like a job within itself. If you can account for delays before they happen and manage to be aware of a claim’s status through the submission and reimbursement processes, you’ll save both time and money.

Have no fear, our tips on how to know if your claim was approved are here.

Types of Claims

Before I break down and provide you with all of the necessary information you need to ensure the status of the claims you submit, we need to establish some common ground.

There are two general buckets that claims tend to land in…cashless and reimbursement.

Cashless Claim

A cashless claim is when a policy holder’s medical and/or treatment bills settle directly between an insurance company and their in-network hospital.

Any charges that are beyond the set limitations of the health insurance policy have to settle between the insured and the hospital.

Reimbursement Claim

If the patient chooses to seek treatment in a non-listed hospital or an out-of-network hospital, he or she will need to pay the bill first before seeking reimbursement from their insurance company.

Common Claim Delays

You’re probably wondering why you’ve been waiting so long for to hear back regarding the status of the claim you submitted. Was it approved or denied? Health insurance companies can sometimes be slow when processing claims.

In some cases, a delay in a health insurance claim is due to the payer investigating the claim and finding that it doesn’t fall under the scope of the health plan’s coverage.

Sometimes, those delays are simply due to miscommunication or missing information. Each health care plan has its own set of guidelines to follow while submitting a claim. In other words, it isn’t unheard of for an insurer to lose vital claim information throughout their process.

Delay 1: Additional Information Needed

As already mentioned, health care plans each have their own specific guidelines on the information needed to submit a claim.

These guidelines will usually address the following items:

Name of the insurance company.
Name of the plan holder.
Group ID number.
Whether the injury or illness is work-related.
Date of the medical service.
Services and/or procedures correspond with proper medical codes.
Itemized charges for each treatment or procedure.

Something as small as misspelling a name can delay your claim for weeks.

Sending your claim to a clearinghouse before submitting it to the payer can save you both time and money. If incorrect information exists within a claim, a clearinghouse can catch this mistake and alert you to this faster than waiting on a payer to deny it.

Delay 2: Coding Mistakes

Welcome to the world of medical coding!

There are five major types of coding classification systems that medical coding professionals use:

ICD-11
ICD-10-CM
ICD-10-PCS
CPT
HCPCS Level II

If you don’t work in the medical coding field, this will probably mean nothing to you. However, making sure that the correct codes are being used before submitting a claim can mean the difference between a quick return of the claim or a delay.

In many cases, sloppy documentation by physicians or other healthcare professionals is the reason for incorrect medical coding. When it’s difficult for medical billing specialists to read handwriting and assign the right codes, this can lead to mistakes and undercoding.

Of course, if you were to ask physicians about this they would beg to differ and instead insist the miscommunication stems from hurried intake by the billing specialist. After all, entering incorrect information for providers is one of the most common mistakes. This is true especially in the case of emergencies when gathering data isn’t the priority during a medical visit and can cause issues down the road.

There are times when specialists use separate codes for linked procedures when there should be a single code used. The technical term for this scenario is ‘unbundling’. Which is an illegal act that can not only increase your total claim amount but can inflate your profit.

Spending time to make sure your billing department receives proper training and is up to date on coding best practices is a worthwhile investment if I haven’t made that obvious enough by now!

In an event that your team accidentally upcodes a patient, or uses a billing code for a more complicated or expensive service than what actually happened, this can cause a claim delay as well.

On top of a delay since more serious codes call for larger payments, this illegally inflates your revenue too.

Just when you thought there could be no more coding mistakes, here are a few more. The opposite of upcoding is, you guessed it: undercoding. This happens when patients are not billed for all of their treatments and/or services. Sure, the patient might not have a complaint with this, but the payer will.

This isn’t a comprehensive list of coding errors, but it's sure to get you thinking about future claim delays and how to prepare to submit them.

Delay 3: Late Submission of Claims

This might be an obvious statement, but making sure you submit your claims in a timely manner can also help you avoid long delays. This time frame can depend on the insurance used by the patient.

If you’re unsure about a specific insurance company’s filing limits, health insurance companies will publish provider manuals with information regarding submitting claims.

These will contain different kinds of information on claim submission and reimbursement processes, including any defined timely filing limit.

Delay 4: Prior Authorization Requirement

Prior authorization, sometimes called precertification or prior approval, is another important factor to take into consideration if you want to avoid lengthy delays.

There are times when payers will require this cost-control process in which providers must receive permission from a health plan before delivering a specific service to the patient to qualify for payment coverage.

In other words, if a physician prescribes a more expensive drug to a patient when a cheaper drug that treats the same illness is available, a health care plan may need to know why that physician can’t use the cheaper medication. If the provider is able to show that the expensive drug is the better option, it may then be pre-authorized.

If the prior authorization process doesn’t happen, all of the claims that didn’t go through the same will come back as a denial.Trust me, you don’t want to deal with prior authorization denials.

Real-Time Claim Status Checks

I have to come clean on something. We’ve only just scratched the surface when it comes to claim delays. There are so many other factors that could go wrong during your revenue cycle that could have an significant impact on your cashflow.

At the end of the day, a delayed claim means that you’re not getting paid when you should.

Worse yet, it takes almost an entire week after you submit a claim to a payer before they tell you why it’s delayed. Talk about making it difficult to predict your revenue.

Sounds pretty hopeless, right?

Well, Etactics provides a real-time claim status service that allows for organizations to see what’s happening with their submissions once they’re sent to a payer. That way, you can spot common claim mistakes before they happen and better predict your cashflow.

Conclusion

Claim delays aren’t the end of the world, but they can be a huge pain and a drain on your resources. It is always helpful to go into filing a claim with as much information as possible to avoid possible delays and denials. When you are unsure of a claim and if it will be accepted, your only option isn’t just to submit it and keep your fingers crossed.

As I mentioned earlier, sending your claims through a clearinghouse is a great way to avoid unnecessary delays and keep your revenue cycle flowing smoothly.

This method of sending patient information to a clearinghouse allows you to receive notification on any corrections that you might need before they’re filed with the insurance company. Having a better insight on your claim filing process will not only save you time and headaches, but also money!