One of the minefields practitioners have to deal with, during the complicated and oftentimes overly drawn-out medical billing process is claim submission — it’s a step rife with all manner of pitfalls and powder kegs that might end up affecting how fast you get paid. In this article, we’re going to tell you what the claim submission process is, the steps you can take to avoid the hazards of medical claim submission — and, overall, how to successfully navigate those confusing waters easily and in an optimized manner. Let’s take a look at the claim submission process in medical billing.

What is the claim submission in medical billing?

The claim submission process in medical billing is one of the many steps you have to take to get paid, as a practitioner, for your services. It is one of the most crucial steps when it comes to the medical billing process. Why? Because in many cases, an error in this particular step might end up derailing your whole process — and either get your claims denied by Alberta Health, not be paid fully for work performed, or even increase the risk of an audit.

Claim submission is defined as the process by which you, the healthcare provider, determine the amount of reimbursement that you will receive after Alberta Health evaluates the information. The more accurate and reflective of the work performed — the quicker you get paid and receive your money.

Clean percentage in claim submission

Maintaining a clean submission record that is reflective of the work performed and supported with proper documentation is important. Why? This leads to less deficiencies and reasons to clawback earnings in the audit. Along with other factors such as historical consistency, percentile thresholds, and outliers, Alberta Health takes this into account when deciding how rigorous they need to look into your claim outside of the standard processing channels. Keeping up a high level of accuracy and low rejection rates are key to running a profitable, effective, and income fluid practice.

claim submission accuracy

Tips on how to master the medical claim submission process — how to achieve a high percentage of clean submissions.

It’s key when recording, submitting, or passing along medical claim data to understand the process and to have insight on how to spearhead it effectively. How to convert deficiencies or rejections into revisions and approvals. The cleaner your claim submission rate, the better and more robust your whole practice will be from an economic point of view.

Ensure updated patient information and records on claims

Accuracy of the patient’s information is core to a claim. This is the soul and heart of the claim submission process. Maintaining your patient details updated is essential for not only a quality service but for your medical billing afterward. Things like current Alberta Health information (ULI), demographics, and medical data will be critical to your claim submission outcome.

Verify patient eligibility at least two days before the Service Date

If applicable, try and make sure your client/patient is eligible for services at least two dates before the service date. This will help you lessen any denials due to the lack of Alberta health care coverage. As goodwill claims are no longer paid for, this is becoming more and more important to stay ahead of the curve on

Remain updated with medical coding regulations

Regulations and updates around coding are changing constantly and it’s difficult to stay on top of. That said, it’s incredibly important to know the current coding otherwise your claim submission could be denied or paid out at a lower rate than necessary. Filing incorrect codes will bring down your claim success rate and increase the potential for an audit in the future. Top medical billing agents are up to date with more of these changes.

Ensure correct modifier usage

Implicit modifiers are handled by Alberta Health but explicit modifiers are not. These are dependent on various elements that need to be present in order to append to a claim - whether driven by patient demographics, length of visit, time of day, or more. Make sure you (or your agent) is up to speed with the current framework and mapping this to claim submissions for accuracy.

working on medical claim submission

Perform quality checks

Check everything twice — and then check again. It’s important to submit your claim only when it’s been scrubbed and edited of all errors. This means focusing on the diagnostic code and its correlation to the health service codes, modifiers, patient information, and cross-referencing clinical notes.

Why? Because claim submissions are adjudicated by advanced algorithms. These algorithms learn and part of their learning is that they start to take more time while analyzing a claim from a practitioner that has a bad claim rate or is presenting information that shows as an outlier (whether monetary related, specialty related, or otherwise).

Maintain proper medical documentation

Finally, the better your practice is at maintaining documented medical records, the more effective it will be throughout the whole billing process. The medical claim submission process is strongly tied to how you document everything. The more documentation, the better. An audit is something best avoided and the best way to come out on top in an audit is to maintain rigorous records that tie to the claims submitted.

What does a smooth and properly performed medical claim submission process ensure?

The claim submission process is by far one of the most important steps in the medical billing process. It allows you to grow your practice by boosting your income stream and allowing you to obtain faster reimbursements. If you aren’t confident in being able to manage this process by yourself (whether through software such as an EMR or otherwise), it is best to look for specialists that can help ensure you are fully covered across the board.

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About ResolvMD:

ResolvMD is an experienced full service medical billing company that empowers physicians to bill more efficiently through data-derived insights and democratized knowledge. We believe you should be as confident and competent in your billing as you are in your practice. Our proprietary Physician Insights Portal harnesses the power of data to deliver customized insights directly to you in real time. No more second guessing or feeling like you don’t have the transparency and accountability that you deserve. Paired with the most modern and secure platform on the market, you can rest easy knowing that we are taking care of all your billing needs while fine tuning your ability to understand best practices and earn what you deserve.