Healthcare Claims Processing:
Increase Efficiency and Decrease Costs

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

Step 1: Insurance verification and eligibility

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: Increase approval rates by automating eligibility for claim acceptance before the claims are even submitted.

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.

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 to easily compare and combine information from multiple sources. This also includes pulling data from any submitted UB-04 / HCFA 1500 forms.

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 software immediately detects denials and flags them, which alerts Providers to act upon them quickly.

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.