How Does Healthcare Reimbursement Work?

It’s no secret that the healthcare industry in America is uniquely complex and full of minutiae that can make or break a practice’s financial health and reduce its’ ability to serve patients well. Rather than being paid up-front for services rendered to patients, private practices are reimbursed sometimes months after the initial appointment. This tedious process involves multiple complicated steps and often results in denied claims due to easy-to-make mistakes or insurance companies’ failures.

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 make sure the information you transfer to an insurance claim is accurate so it won’t be denied.

PayrHealth benefits practices by automating data collection and claim filing, using proprietary tools to “scrub” claims for the most common mistakes that result in denied claims, so your acceptance rate on the first submission rises and the time spent preparing claims diminishes.

2. Assign the Appropriate Codes for Treatment Services Rendered

Insurance companies 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 a standardized reimbursement rate at the granular level for everything from surgical techniques to in-office exams and consultations.

Every code (and there are tens of thousands of different codes) is linked to a reimbursement rate that is negotiated between the practice and the insurer. 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 could lead to a lack of full reimbursement for the real services provided, and mis-assigning codes can cause payors to deny claims even if they cover the actual procedure.

3. Submit the Claim

While many practices choose to manually file claims with their 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 you get every penny you’re owed. Our software standardizes claim forms to ensure every payor you’re contracted with receives clean, interpretable claims every time.

4. Deal With Payor Rejections

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

  • Misfiled claim codes
  • Improper service offerings for a single visit
  • Patients’ lack of coverage
  • Lack of medical necessity

However, in many of these cases, an argument can be made to reverse the payor’s decision, helping you boost revenue. Re-submitting and escalating claims is time-consuming, however, and requires at least a little data to back up your position. 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 Reimbursement

As costs of providing services continue to inflate, it’s becoming harder and harder for independent 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 reimbursement boosting strategies by calling us or contacting us online today.