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The Five Vital Steps in Getting a Medical Claim Paid

By March 22, 2023No Comments

Everyone knows that medical billing is very complex, time-consuming, and frustrating. You can do everything correctly and the carriers can still deny the claim.

In addition to carrier claim denials, staffing has become a never-ending uphill battle especially in the post-pandemic years resulting in a severe shortage of available staff and workers wanting to work from home.

If your practice is doing billing in-house, you must have a competent and knowledgeable staff to execute the following vital steps to assure that your claims are paid.

1. Patient Demographics

Getting up-to-date patient and insurance information is essential to getting claims paid. Verify Insurance information at each visit unless the patient is under current care.  Patient insurance coverage can change at any time. Make sure your staff is getting eyes on the insurance card and scanning it into your system to ensure accurate entry.

2. Charge Entry

Most practices now utilize an EMR that determines the CPT code(s) and accompanying ICD-10 code(s). These days that is not enough.  Many insurance carriers have unique diagnosis(es) that must be matched with the procedure code(s).  These may be supplemental diagnoses not automatically programmed by the EMR.  If the carrier has a consistent pattern of denials, staff should inform the practice providers so that they can change their coding, if appropriate, or contact the carrier’s contract representative to address these excessive denials.

3. Payment Posting

Perform payment posting as close to real-time as possible. The longer it takes to post payments from carriers, the longer it will take to:

  • Identify a denial
  • Resubmit a claim with corrections or attachments
  • Balance bill patients

4.  Working the Accounts Receivables

The AR staff has three basic functions:

  • Responding to correspondence received daily
  • Working and completing the monthly AR report that summarizes all unpaid claims 35 days or older from original date of service is essential
  • Addressing denials forwarded by the Payment Posting Department daily or requests for medical records by carriers.

A recent trend by carriers is denying claims until documentation of the service(s) billed is received.  Although in most cases the claims are paid, it is used as a stall tactic to delay payment.

IEBC Recommendation:  An AR spreadsheet should be developed so that the practice owner(s) can monitor the over 90-day percentage and dollar amounts and compare changes month-to-month.  The over 90-day percentage should not exceed 15%.  Industry benchmarks of excellence are set at under 10%.  The exception is if outstanding claims are in review and/or awaiting carrier adjudication.  Claims in pre- or post-payment review should not appear on the report but followed separately. The Inga Ellzey Billing Companies have a full-time auditor that reviews denials daily and responds to requests within days to avoid unnecessary delays.  Additionally, the documentation is reviewed to assure that the chart notes support the services billed.

5. Sending Monthly Patient Statements

Balance billing patients for their portion of the charged amount should be done no less than monthly. The best way to send statements is sending a portion of the patient-owed balances report each week.  Transmitting statements weekly spreads out the incoming patient phone calls and increases the probability of receiving payment.


Consistent delays in working the AR report or sending patient statements represent the two most common tasks that are not performed regularly or in a timely fashion.  The result is a delay in payments and lost revenue.

If your staff is not completing or addressing these five essential components of billing in a timely or effective manner, it most likely indicates:

  • You are understaffed
  • Have staff not properly trained
  • Have staff lacking billing experience
  • Have outdated or ineffective policies and procedures

The billing industry has changed drastically in the past five years.  Practices can no longer depend on Judy or the girls down the hall to handle all the endless daily, weekly, and monthly functions.  (The exception is smaller practices that are not interested in growth, adding new providers, or contemplating selling the practice to Private Equity.)

If you have a dynamic practice with a one-to-five-year growth plan, contact The Inga Ellzey Billing Companies and allow us to do a no-obligation analysis of your aging report, collection and adjustment ratios, and fee schedule.  This cursory examination will allow you to be able to evaluate the effectiveness of your practice’s billing component.


What are the common errors made when processing medical claims?

The errors frequently made when processing medical claims range from incorrect or incomplete patient information, inaccurate coding, lack of documentation, duplicate billing, and more.

What are the consequences of processing medical claims incorrectly?

If medical claims aren’t processed correctly, payments are usually delayed. There are other issues, too: administrative costs are increased, and there are potentially legal issues that can come into play. On top of that, patient dissatisfaction and loss of reputation are important to consider as long-term effects of improperly processed medical claims.

What is the average success rate for processing medical claims?

The average success rate for processing medical claims can vary depending on several factors, including the provider’s office, the insurance company, and the efficiency of the claims department. In addition, the cost of health treatment and the number of claims being processed can also impact the success rate.

If you have any issues with processing medical claims for your practice, trust our expert team. Contact us for a no-obligation analysis of your aging report, collection and adjustment ratios, and fee schedule.


About Inga Ellzey Billing Companies Inga Ellzey Billing Companies is a leading provider of medical billing services with almost 30 years of experience. The company offers a comprehensive range of service, including coding and billing, claims management, patient collections, and revenue cycle management, to help dermatologists providers optimize their operations and improve their revenue cycle management.

For more information about our dermatology billing services contact us via our website.

Read more from our published resources:
Virtual Supervision: Expanding Access to Healthcare during the PHE
Overcoming Q1 Cashflow Challenges in Dermatology Practices
2023 Revised Conversion Factor & Medicare Fee Schedule Update


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