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The healthcare systems around the world are billions of dollars in worth – in the US alone, it is a trillion-dollar industry. These include pharmacies, pharmaceutical companies, medical equipment manufacturers, medical care facilities, etc. The key part of this complex industry is the healthcare insurance sector which is responsible for the well-being of billions of people.

The healthcare insurance sector is dynamic and new operating processes keep coming into the spotlight. To thrive in such an industry, medical insurance providers need to focus on marketing and enrollment, customer retention and maintaining equilibrium between profitability, purpose and perceived value.

Challenges Faced by Small Healthcare Providers

The owners of small healthcare providers have many advantages at their disposal. They may benefit from and enjoy working alone or with just a couple of practitioners. They get the opportunity to work or help with  patients on a more personal level which often leads to better care management and outcomes. They become someone who knows their community’s healthcare needs and end up making a positive impact on their customers. 

However, small healthcare providers have their own set of problems. Running a small practice requires only limited staff who end up having their hands in everything ranging from patient access to claims management, unlike healthcare providers of hospitals or health systems. Healthcare providers of all sizes are having trouble adjusting their revenue cycle to accommodate billing changes. Having said that, small practices have their own unique revenue cycle management challenges.

  • Lack of Technological Advancement Smaller practices tend to drag their feet or completely avoid adopting technological infrastructure because of implementation and upkeep costs. They also view automated solutions in a similar light which makes their healthcare revenue cycle processes remain manual.
  • Limited Budget High costs and the eventual expensive upkeep of healthcare technology can be overwhelming for small practices operating on a limited budget.
  • Value-Based Purchasing The payment model of healthcare providers is changing with value-based purchasing, where healthcare providers are accountable for both the quality and cost of the care provided. The transition to this new payment model is leading to the restructuring of revenue cycle management to include new tools and capabilities such as data analytics, monitoring of quality and cost performance and standardization of care. But smaller practices often have a hard time with the implementation of value-based purchasing which eventually leads to closures and increased merger activity.
  • Patient Payments A significant number of physicians feel that it is a huge roadblock to collect payments from the patients directly. With the rise of high deductible plans, it is getting harder for practices to receive enough patient payments to maintain their bottom line. This problem has become unavoidable and is something that every small practice is facing now. To add to this, a lot of physicians also have trouble with third party reimbursements.

Claims Processing System

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Medical claims processing involves coordination between two of the most vital fragments of the healthcare industry: healthcare providers and medical insurance companies. The challenges are multi-layered when it comes to medical claims processing – volume, accuracy, processing speed, cost of administration and compliance of regulations, etc. all have a hand in improving customer satisfaction.

The key players in the medical claims process are the healthcare providers, insurance companies and policyholders –

  • Healthcare providers can be hospitals, private clinics, pharmacies as well as providers of specialized care like nursing homes, in-house caretakers or chiropractors.
  • Insurance policies of various companies may be different but all of them have a similar working model wherein a policyholder pays a certain amount of money monthly or annually to the insurance company, which is called a premium. The insurance company then pays the amount either in full or partially to an eligible policyholder for the required medical procedure or service.
  • Any individual who has purchased health insurance is a policyholder. The policyholder must pay a prearranged amount to the insurance company for them to later cover the costs of any medical procedure or service that the policyholder may incur in the future.

Why should you Outsource your Claims Processing?

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Insurance policies often have long term validities going on for years. The responsibilities of insurance companies to deliver on the services promised are enormous and are hard for one immersed in other critical duties. Outsourcing the processing of claims leads to many advantages and opportunities.

  1. Reduced Administrative Duties – Outsourcing your medical billing can leave the staff to attend to more demanding factors like educating patients regarding their conditions or responding to their inquiries.
  2. Efficient Workflow – Verifying patience coverage automatically can be a huge burden off the shoulders of smaller practices. The information concerning a patient such as finding out they have met their deductible, if they have maxed out their number of visits for a particular case or if they have become ineligible because some reason or the other can all be accessed in a quick and precise manner.
  3. Process Claims Faster – Outsourcing routine administrative tasks result in your business working more productively and efficiently. A paper-based claim can take months to deliver the reimbursement whereas a clean claim expedited and coded appropriately for maximum reimbursement, with the support of EHR can result in full payment in 7 to 10 days.
  4. Elimination of Billing and Coding Errors – A reputable medical billing partner can provide hard factual data that is needed to keep an eye on the financial aspects of the organization. All the data outsourced are arranged in a precise and correct manner leaving no room for errors.
  5. Securing your Data – Assigning your medical billing to a professional firm leads to your patient information being more secure as these companies invest a lot of money to keep the possibility of a data breach to a minimum.

Debunking Myths about Outsourcing your Claims Services

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There are a large number of misconceptions surrounding outsourcing your services. Most of them are inaccurate, like-

  • You may lose control over your revenue process
    Medical billing services manage revenue generation and reconciliation. The outsourced companies only look at a specified task of the practice and report accordingly.
  • Outsourcing is expensive
    It may seem expensive to hire an external billing provider but the revenues can also be boosted significantly. They improve and increase the revenue cycles of a business.
  • It is limited to data entry
    A medical coder needs to read and understand medical records or notes, decide on the information’s relevance and translate it into respective codes.
  • No ROI in RCM technology
    Outsourcing Revenue Cycle Management offers benefits by integrating financials with patient portraits, offering electronic payment options, sending electronic statements and reminders, offering to pre-pay options to patients, etc. All of these and more ensures strong reimbursement and strengthened cash flow which provides quantifiable ROI on the technology and services invested.

Expertcallers is a 100% HIPAA compliant medical and healthcare call center service provider with over 13 years of experience. As experts in the healthcare call outsourcing services domain, we offer customer support through all in-demand channels. Outsource your healthcare-related call center requirements to ExpertCallers and gain a competitive edge in the marketplace alongside a steady boost in revenue in an otherwise changing healthcare system.