Healthcare Claims Processing:
Increase Efficiency and Decrease Costs

EOB and Claims Processing Software Tools

Top performing hospital systems and clearinghouses are improving patient care using AI acceleration and intelligent document processing. They are also spending less money on critical tasks like:

  • Data input
  • Claims processing
  • Data integrations
  • And supply chain logistics

What is the key to doing this?

The key to quickly achieving sustained net operating margin is optimizing the revenue cycle through better data management.

Here is How We Use AI to Streamline Each Step of the Claims Process:

claim processing system in healthcare

Step 1: Insurance verification and eligibility

healthcare claims processing

When a patient visits a doctor’s office or healthcare provider, manual insurance verification creates many costly opportunities for error. Healthcare centers that do not collect deductibles upfront, or collect the wrong amount, suffer huge revenue losses.

This is an increasingly critical situation as more patients have higher deductibles and maximums.

Our solution: Leverage Grooper AI acceleration to increase approval rates by automating eligibility for claim acceptance before the claims are even submitted.

healthcare claims processing workflow

Step 2: Data entry and patient demographics

After the patient leaves the doctor’s office, accurate entry of patient demographic information is vital for claims acceptance. Errors slow the revenue cycle, hurt the patient experience, and create additional work.

Our solution: Create workflows that validate information and flag any patient record missing key documentation.

Grooper reads forms and recognizes checkboxes without requiring complex templates, and flags any errors for humans to review them. This streamlines all paper, digital, and mixed registration processes in order to submit accurate 837 claim forms – and speeds up the entire process.

claim denial management

Step 3: Pre-screening EDI 837 for errors

Forms such as 837 require:

  • An accurate description of the patient
  • The condition for which treatment was provided
  • The services performed
  • The cost of treatment

More often than not, these forms are sent to third-party clearinghouses which are a middleman company between the Provider and Payer (the insurance company).

Because the sheer volume of claims submitted every day is growing alongside compliance and rule-changes, manual claims auditing is just not practical. Adding to the difficulty is the fact that Payers / insurance companies each have their own forms and templates which must be used to submit information for claims approvals, so using clearinghouses with smart automation is cost-effective and efficient.

Our solution: Clearinghouses will automatically scrub these forms using intelligent technology and check ICD / CPT codes for errors. The final form will be filed according to the insurance carrier’s standard format. Automation makes catering to thousands of different formats much easier to manage (both on data input and output).

Because this form must be accurate in order to receive payment and to backfill other forms (the 835, for example), clearinghouses use Grooper AI to easily compare and combine information from multiple sources. This also includes pulling data from any submitted UB-04 / HCFA 1500 forms.

medical claims processing

Step 4: Denial management and claims adjudication

As mentioned previously, healthcare clearinghouse companies will use data from the 837 form to create accurate and complete 835 forms to communicate what charges were paid, reduced, or denied, and additional payment information.

It is inevitable that some of these claims will be denied. But retrospective denials are an industry silent killer of net revenue.

Retrospective denials are more tricky to act upon because they are easily missed and will happen long after the original claim was submitted.

Our solution: Grooper AI accelerates this workflow, as it immediately detects denials and flags them, which alerts Providers to act upon them quickly.

healthcare claims processing software

Step 5: Recognize revenue quicker by decreasing days in accounts receivable

Getting claims accurately filed is only half the battle. Providers with faster financial processing workflows get their revenue faster by decreasing accounts receivable times.

As a result, electronically processing EOBs and bank statement information with intelligent automation is critical.

Our solution: Managing BAI and ACH files with Grooper makes quick work of processing CTX, PPD, and CCD addendum records.

In typical scenarios robotic process automation (RPA) will deliver up these files, including correspondence documents, to Grooper for validation. Workflows then route information to human workers as needed and finally back to RPA bots for further processing.

A New Solution for EOB Processing

healthcare claims processing overview

Onboarding new Payers and Providers is faster now than ever. Gone are the days of hard-coded claim extraction templates. Insurance companies have created over 6,000 different EOB layouts, so hard-coding templates for even 80% of them is not an effective solution.

EOB processing has been forever changed.

This is possible through AI acceleration, which uses Smart Label Classification to onboard hundreds of EOBs in days, not weeks.

Smart Label Classification classifies documents based on labels within a document, treating them as a “fingerprint.” This method provides reliable classification on complex, semi-structured documents.

Read so much more about our industry-best EOB conversion solutions!

4 Healthcare Claims Processing Solutions:

healthcare tech rcm icon

Revenue and Payment Cycle Management

You can cut days off claims staying in accounts receivable by integrating billing applications with integrated data via automated EOB and claims processing.

  • Process BAI and ACH files along with addendum records (CTX, PPD, and CCD formats) for fast payment processing.
  • Enhance software applications and B2B data conversions for revenue and payment cycle management solutions.
  • Quickly convert electronic and paper claims into EDI for submission.
  • Return valuable revenue through proactive retrospective denial management.
healthcare claims case study

White Paper: Success for Healthcare Clearinghouses

Learn how healthcare clearinghouse companies are winning by optimizing their data integration. Check out our white paper!

claims processing software healthcare

Healthcare Data Integration

Because of the wild variety of forms and information used in insurance claims management, intelligent document processing (IDP) is an effective and proven solution to modernize healthcare claims processing.

Integrate your software applications with existing claims management, billing, RPA, and EMR systems. In addition, with Grooper healthcare claim forms processing, you convert a wide variety of forms including the most common claim forms (which are the CMS-1500 / HICFA and UB-04) paper-based claims into 837 files.

Though both of these forms look very similar, they are actually a little different: CMS-1500 forms are used in smaller medical facilities (like private practices). Meanwhile, UB-04 forms are used in large institutional facilities like hospitals.

healthcare electronic claims processing

Robust Information Capture

The benefit of using IDP is end-to-end healthcare data capture. IDP solutions include robust electronic data ingestion, document scanning, high accuracy OCR, document classification, data extraction, external database lookups, rules-based processing, data verification, and integration with RCM software and process automation solutions.

Grooper supports integration for information capture from standard and custom insurance claim forms, reports, e-signature, email, and electronic paper sources, whether machine or human generated. Process thousands of different EOB formats from multiple Payers and normalize ERA / 835 forms.

Intelligent Claims Processing

Intelligent Claims Processing

Process healthcare claims and EOBs the way that humans work. Because IDP uses template auto-builders, onboarding new document types is a streamlined process.

Algorithms intelligently process remark codes and descriptions to flag new Payer specific codes for human review and mapping to standard ANSI codes (or custom overrides) for the 835.

Purpose-built rules engines process data elements on a global, customer, or Payer level. The rules may be as simple as requiring the existence of a data element, or more complex such as requiring data to match a regular expression, or mathematical validation.

In addition, this makes complying with HIPAA regulations even easier as all claims are processed electronically. There are still some manual processes that other claim processing solutions cannot automate. However, in our work with one of the top EOB processing groups in the world, we have automated all of these manual processes.

A 99% Reduction in Processing Time

“We are ecstatic about how well Grooper works on our billing system. We have a customer that submitted a bill with 8,000 lines. These lines totaled over $3,000,000 in fees that needed to be audited.

It took just over 1 minute to process every line, and match up against the total. This would have taken close to 2 hours before.”
Healthcare SaaS Payment Integrity Firm
healthcare technology automated contract abstraction

Mini Case Study

In a recent project, one of the U.S.’s largest healthcare data processing companies needed a solution to process B2B data, billing, and insurance claims information for hundreds of thousands of patients. The workload required on back-end systems and technology service providers was massive.

By using intelligent document processing and Smart Label Classification, they transform gigabyte-sized text files into billions of data extractions every day to complete their mission-critical workflows.

Contact us today for faster and easier healthcare claims processing. Because nobody should have to suffer through painful data integrations.

Healthcare Claims Processing FAQs:

What is a claim?

Basically, a medical claim is an invoice that a doctor or medical clinic submits to a patient’s health insurance company so they can get paid. A claim shows all of the medical services that the provider rendered to the patient, including:
– A medical procedure
– A diagnosis
– Medical devices
– Medical supplies
– Medication / pharmaceuticals

The claim also details the related charges that came with the services. The claims reimbursement process includes many administrative and and approval steps, such as claims review, research, adjusting, and denial or remittance.

What is medical claims processing?

Medical claims processing (or healthcare claims processing) is the process of an insurance company reviewing data in medical claims, then investigating, adjusting and ultimately approving or denying the claim.

The process begins when a healthcare provider submits claim request forms to various insurance companies. This can be done directly, when medical billers who work in that specific medical facility send in claim requests to various insurance companies. Or the process can have an indirect workflow, when a biller sends in claims requests to a third-party health care clearinghouse.

Through the process, there can be dozens of steps among data investigation, adjusting, adjudication and approval. Some of these steps are automated and in many places, these steps are still manually fulfilled.

Healthcare Technology Testimonials

  • “Practically every unit here within our agency uses Grooper on some level. Grooper has cut down on our indexing time by 70 percent.”

    Ryan Freeman-Smith, Manager, Oklahoma Health Care Authority
  • “Grooper deliverers the ability to lift data from multiple mediums (TIF, JPG, text, Word, XML, Excel, PDF, and ETC…) and transform, validate, and output data to multiple sources. Take time to meet with the technical team before you choose another product.

    Grooper enabled Change Healthcare to lift data from very complex client EOB/EOB print files and transform the data into payment and print files.”

    Todd S.
  • “We use Grooper for a lot of accounting purposes, and for all the different types of invoices that we process. One of the reasons we like Grooper is that have one application built within Grooper for our whole accounting department. It contains seven different samples of the different kind of invoices we use, depending on if it’s a travel claim, or if it’s repaying a vendor, or something else. Grooper’s able to just recognize everything.”

    Ryan Freeman-Smith, Manger, Oklahoma Health Care Authority
  • “The quality and efficiency of work and service delivered was more than we could’ve asked for. It’s always been an easy relationship.”

    Gena Cowan, HIM Manager, Mercy Hospital

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