The Best Medicine for Healthcare is Better Medical Billing
An underappreciated source of today's high medical care costs is the medical claim adjudication process that is employed by commercial payers. The current process is intentionally fraught with unnecessary hurdles and pitfalls that save the payers money by lowering the amount they reimburse physicians and facilities. Well designed medical billing processes from medical billing companies and medical offices can eliminate the profitability of the current adjudication process and streamline the entire insurance reimbursement process.
Everyone hears about the fact that much of the cost of healthcare is driven by the expense of processing and adjudicating claims. What is often not mentioned is what is truly at the root of these expenses - payers that are attempting to withhold from physicians the money they are due.
Payers employ a series of complicated (and frequently changing) adjudication rules which medical providers and medical billing services must navigate to obtain payment for services rendered. Even when the maze is navigated successfully, payers will frequently (ten percent to twenty percent of the time) underpay claims. To add insult to injury, payers will also frequently simply "lose" claims that have been submitted. Unless the medical billing process is designed to catch these errors the payers never pay the money that is saved though the underpayment and misplacement of claims.
Now, here is a shocking fact - more than 50 percent of claims that payers "lose" or are underpaid are never pursued by physicians (and therefore the payers never have to pay the money they owe to the physician or facility). This means that payers have a powerful economic incentive to play games and make the medical billing process complicated.
Here is another shocking fact - it costs the average insurance company about $25 each time a representative has to get on the phone and discuss a lost or underpaid claim with a medical billing specialist. A final key fact is that most payers "grade" each provider. The lower a provider's grade (i.e., a D versus an A) the more likely the payers are to lose or under pay the provider's claims. Why? Because these providers have no track record of catching these problems and pursuing them.
If payers had a base of providers that were all diligent and spotted each and every lost or underpaid claim they would quickly discover that there was no economic incentive to play games with how the claims are paid. This is why better medical billing is a key front in the battle against rising healthcare costs.
If the medical practices and medical billing services dig in and fight for the last dollar on every claim they will quickly force the insurance payers to adjust their internal processes. With each claim paying in full and their staff inundated with billing specialist asking why a claim was lost or underpaid, the payers will see rapidly shrinking profits that will force them to acknowledge that the costs of the games they play are no longer justified by the savings form unpaid claims.
Many companies and individuals are dreaming of the day when the medical billing process disappears entirely and claims are adjudicated in real-time while the patient is standing at the checkout desk. In this system significant costs will be saved, but the system will never emerge until payers no longer have an incentive to play games with medical claims. Medical billing companies and medical providers can make this happen by insuring that all providers are rated A in the eyes of each payer.
Carl Mays II is founder and Chairman of ClaimCare <a href="http://www.claimcare.net">Medical Billing Services</a>, one of the largest <a href="http://www.claimcare.net">Medical Billing Companies</a> in the US. Carl has improved the operations of organizations ranging from solo practioners to fortune 500 companies.
