Payor Contracting

How Does Healthcare Reimbursement Work?

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It's no secret that the healthcare system in America is uniquely complex and full of minutiae that can make or break a practice's financial health. These details can reduce your practice's ability to provide good patient outcomes, as well. Rather than being paid up-front for a medical service to patients, private practices are reimbursed by an insurance company sometimes months after the initial appointment. If you're a healthcare provider that relies on healthcare reimbursement, then getting them right in the first place is key to ensuring your costs don't pile up and interfere with your ability to provide vital medical service.

This tedious process involves multiple complicated steps and often results in denied claims due to easy-to-make mistakes or insurance companies' failures. Reimbursements are an essential part of your practice's success whether you're a hospital, diagnostic facility, or private practice provider, so here is a step-by-step guide on what to know about how healthcare reimbursement works - and how PayrHealth can help.

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1. Enter Patient and Treatment Data

These days, it's nearly impossible to get by without a robust electronic health record (EHR) database that captures and organizes the reams of data your practice generates on a daily basis. Correct data entry at this stage is crucial to making sure the information you transfer to a health insurer is accurate - and won't be denied.

PayrHealth can automate your healthcare practice's data collection and claim filing, using proprietary tools to "scrub" claims for the most common mistakes that result in denied claims. With this unique tool, your acceptance rate on the first submission rises and the time spent preparing claims diminishes.

2. Assign the Appropriate Codes for Services Rendered

Health insurers don't pay out reimbursements with narrative information about the diagnosis and treatment plan, but rather with itemized medical codes including the International Classification of Diseases (ICD-10) as well as Current Procedural Terminology (CPT) codes. This allows for standardized reimbursement rates at the granular level for everything from surgical techniques to in-office exams and consultations with providers.

Every code (and there are tens of thousands of different codes) is linked to a reimbursement rate that is negotiated between the provider and the insurer, sometimes called a health reimbursement arrangement. This fee-for-service model of reimbursement incentivizes practices to provide as many services as possible to maximize their reimbursement from insurance companies. These rates can be negotiated with commercial insurers like Aetna and BCBS, but can't be changed with government health plans like Medicare.

Failing to assign all the necessary codes can lead to a lack of full reimbursement for the real services provided. In fact, it's one of the most common mistakes made when submitting claims. And making mistakes with codes can cause payors to deny claims or not provide the agreed upon amount even if they cover the actual procedure.

3. Submit the Claim

While many providers choose to manually submit claims with their health insurance partners, PayrHealth takes this hassle and risk of error out of the equation with our automated claims filing procedure. With revenue cycle management, we handle all aspects of the claim submission process, including following up on and escalating denied claims to make sure your provider gets every penny they're owed. Our software standardizes claim forms to ensure every insurance health insurance company you're contracted with receives clean, interpretable claims every time. This can not only save time and offset medical costs, but boost your provider's ability to get back to providing patients with exceptional care.

4. Deal With Healthcare Reimbursement Rejections

Payors often reject reimbursement claims for a number of reasons, the most common being:

  • Misfiled claim codes
  • Improper medical service offerings for a single visit
  • Lack of patient healthcare coverage
  • Lack of medical necessity

However, in many of these cases, an argument can be made to reverse the payor's decision, making certain the insurer pays and helping you boost revenue. Re-submitting and escalating claims with a health insurance company is time-consuming, however, and requires at least a little data to back up your position and obtain the agreed upon amount. PayrHealth handles all claim resubmission processes and escalations through our revenue cycle management solution, allowing your team to focus on providing top-notch patient care while reaping the benefits of following up on denials.

PayrHealth Simplifies Healthcare Reimbursement

As the total cost of providing services continues to inflate, it's becoming harder and harder for independent healthcare providers to serve their patients with quality care at a sustainable financial state. By partnering with PayrHealth, we can help identify your areas of revenue leakage and work together to solve them, ensuring you're paid on-time and in full. Learn more about our healthcare reimbursement boosting strategies by calling us or contacting us online today.

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Payrhealth is a full-service payor-provider relationship manager. We see a future where providers and payors can make more informed decisions together to build a strengthened healthcare system. Learn more through a free consultation with our world-class experts today.

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