A provider submits accurate and clean claims to pass them through adjudication. Adjudication in medical billing is a payer’s evaluation and final decision before reimbursing a healthcare provider. The adjudication is a payer-driven process that verifies the validity of the submitted claims. Outsourcing medical billing audit services can help providers evaluate and verify claims before submitting them to the payer. The adjudication procedure may seem simple, but it’s not. You’ll get to know more in this blog.
The evaluation of the claims to check their effectiveness and accuracy is called adjudication in medical billing. The payer assesses the claim for the patient’s information to ensure accuracy. Likewise, it reviews the medical codes using the Current Procedural Terminology (CPT codes) and the Healthcare Common Procedure Coding System (HCPCS).
Moving forward, the payer reviews the legality of the services rendered. For example, if the rendered service is for podiatry, then the payer will evaluate the medical codes of podiatry medical billing to verify the claim. After reviewing all the requirements, the payer either accepts the claims or denies them due to inaccuracy.
After the complete evaluation, the payor makes the decision regarding claims. It either rejects the claim due to missing or inaccurate information or reimburses it as per the insurance policy. The payor provides a valid reason for denying the claim, usually through a Remittance Advice (RA) or Explanation of Benefits (EOB). After correcting the claim, the provider appeals for an AR recovery process.
To achieve revenue optimization in healthcare, it is crucial to submit error-free claims. A clean claim is the foundation of efficient financial health. It can happen by following the adjudication standardization set by the payer.
