Your practice is seeing patients and submitting claims, but payments aren’t coming in as quickly as you’d like. Your billing team is stretched thin, and the pile of unpaid claims keeps growing.
Where is the money getting held up?
Medical claims processing involves more than sending claims to insurance companies. Coding delays, rejected claims, and missed follow-ups can all slow down payment. Finding out where claims get stuck can help you fix problems before they affect your cash flow.
Where Do Delays Happen in Medical Claims Processing?
Every claim goes through several steps before your practice gets paid. A problem at any stage can hold up payment, sometimes without your team realizing it.
1. Insurance Verification
Outdated insurance details, inactive coverage, or missing prior authorizations can cause problems before a claim is even submitted. Checking this information before the patient’s visit can prevent delays later.
2. Medical Coding and Charge Entry
Coding backlogs can leave claims waiting for days. Incorrect codes, missing documentation, or charges that don’t match the medical records can also lead to rejections or denials.
3. Claim Submission
Clearinghouses catch many errors before claims reach insurers. But rejected claims still need attention. If your team doesn’t correct and resubmit them promptly, payment gets pushed back.
4. Insurance Review
Insurers may request additional records, question medical necessity, or take longer than expected to review claims. Without regular status checks, these claims can sit unpaid while your staff assumes they’re still being processed.
5. Payment Posting
An insurer may pay less than your practice expects. If your team doesn’t compare payments with contracted rates and review adjustments, underpayments can go unnoticed.
6. Unpaid Claim Follow-Up
Claims can fall through the cracks when staff are busy with other tasks. Delayed follow-up can lead to growing unpaid balances, missed appeal deadlines, and claims that become harder to collect.
How Can You Tell If Your Claims Process Is Working?
Submitting claims on time is important, but it doesn’t tell you whether your billing process is working well.
A few key numbers can give you a clearer picture:
- Clean claim rate: The percentage of claims submitted without errors that require correction.
- First-pass acceptance rate: The percentage of claims accepted by a clearinghouse or payer on their first submission.
- Days in accounts receivable: A measure of how long your practice takes to collect outstanding payments.
- Claims over 90 days old: The share of unpaid balances that have been outstanding for more than three months.
If these numbers are moving in the wrong direction, your practice may have a problem that needs immediate attention.
For example, a rising number of older claims could mean your team isn’t following up quickly enough. A low clean claim rate may point to problems with coding or patient information.
How Do Delayed Claims Affect Cash Flow?
Your practice still needs to cover payroll, rent, supplies, and other expenses while waiting for insurance payments.
When claims sit unpaid, money you’ve already earned stays tied up in accounts receivable. Even a busy practice can run into cash flow problems when payments fall behind.
Catching errors early, submitting claims promptly, and following up regularly can reduce delays and make revenue easier to manage.
When Should You Outsource Medical Claims Processing?
If your billing team is constantly playing catch-up, outsourcing may be worth considering.
Common signs include growing accounts receivable, frequent coding backlogs, missed follow-ups, and staff who don’t have enough time to manage billing alongside other duties.
An outside billing team can manage coding, claim submission, payment posting, and follow-up. That means fewer billing tasks competing for your staff’s time and more consistent attention to unpaid claims.
Improve Medical Claims Processing With Oclinicals
Are unpaid claims piling up while your staff struggles to keep up with billing?
Oclinicals provides medical billing and coding services for practices that need more support. Our team handles claims from submission through payment posting and follow-up, reducing the billing workload on your staff.
Contact Oclinicals today to learn how our medical billing and coding services can reduce billing backlogs, improve claim follow-up, and take work off your staff’s plate.