Reprocessing Medical Bills 

Although often overlooked in healthcare discussions, one critical component of healthcare financial management is the reprocessing of medical bills. Reprocessing refers to the review, adjustment, and resubmission of healthcare claims to ensure accurate reimbursement for services rendered (1). Reprocessing claims includes two separate types of appeals to health insurance organizations: resubmissions, which occur when a claim has been rejected due to time restraints, insurance caveats, or lack of stipulated necessity; and corrections, which occur when a claim has been denied due to incorrect coding, billing mistakes, or other errors (2). In recent years, claim denials and rejections have increased significantly, with physicians reporting an uptick of 17% in denials in 2021 (3). However, an estimated two-thirds of rejected claims are amendable; therefore, reprocessing medical bills is a valuable process that carries several potential benefits for patients and their providers (3).   

On the patients’ end, reprocessing medical bills can improve patient safety and satisfaction. First, as reprocessing ensures that claims follow insurance policies, prior authorization requirements, regulatory guidelines, and quality standards, the system protects patients by ensuring that patients receive medically necessary care that adheres to regulatory standards (4). Second, as financial considerations comprise a large portion of patient satisfaction, accurate and timely billing processes are crucial for maintaining positive relationships between patients and their providers (5). By reprocessing medical bills, providers can address any billing errors promptly, preventing incorrect charges or disputes. Adequate financial management leads to better patient experiences, improved trust in healthcare providers, and strengthened patient-provider relationships (5). 

For providers, the benefits of reprocessing medical claims stem from the restoration of lost or delayed revenue. Before claims reach insurance organizations, they may be processed by a clearinghouse, which assesses them for accuracy, compliance, and medical necessity; thus, claim rejections and denials from the clearinghouse result in delays in reimbursement from the health insurance organization (3). Accurate, timely reimbursement from health insurance organizations is essential for healthcare providers to sustain their operations and continue delivering quality care to patients; however, due to the complex nature of medical billing, errors and discrepancies often occur, resulting in claim rejections and denials that lead to denied or delayed payment (6). Reprocessing medical bills allows providers to rectify billing errors, reconcile claims, and ensure fair compensation for their services (3). Thus, reprocessing medical bills can lead to rectified revenue for healthcare providers. Additionally, confirming details of medical treatment and ensuring regulation adherence through claim resubmission ensures that providers deliver safe, correct care for each patient (3).  

Although reprocessing medical bills offers benefits for both patients and providers, the process presents significant challenges. For providers, reprocessing bills requires intricate knowledge of insurance systems, regulations, and payer-specific requirements, resulting in a difficult filing process (1). Reprocessing previously denied claims requires significant attention to detail and extensive corrections, a process that can be time-consuming and resource-intensive, with no guarantee that the appeal will be accepted (2, 3). To ensure that reprocessed claims are accepted, experts recommend implementing denial prevention and management strategies (4, 6). Before submitting claims, providers should ensure that they avoid common errors that cause clearinghouses to deny or reject claims — for example, 25% of denied claims are declined due to prior authorization issues, 15% due to incomplete information, 21% due to issues related to coverage and medical necessity, and 15% due to coding errors (6). To avoid these common issues, experts suggest verifying coverage, providing adequate training to administrative staff, adhering to insurance deadlines, and utilizing an electronic claim management system (4, 6). To address denied or rejected claims, providers should develop an algorithm for administrative staff that includes a designated error-checking process, insurance verification procedure, and usage of an appeal letter template to promptly resubmit claims (6). Despite the complexity of the medical claim resubmission process, preventing and addressing errors increases the chance of acceptance, restoring revenue to providers and alleviating financial stress from patients. 

References 

1: Hurt, A. 2019. Resubmitting claims: get it right the second time. Physicians Practice. URL: https://www.physicianspractice.com/view/resubmitting-claims-get-it-right-second-time.  

2: Craig, C. 2019. Know the difference: Medicare rejections, denials, appeals, and reopenings. CIPROMS. URL: https://www.ciproms.com/2019/03/know-the-difference-medicare-rejections-denials-appeals-and-reopenings/.  

3: Poland, L. 2022. Claims denials: a step-by-step approach to resolution. Journal of AHIMA. URL: https://journal.ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution.  

4: Davis, E. 2023. Reasons for health insurance claim denials and what you should do. VeryWell Health. URL: https://www.verywellhealth.com/what-is-a-health-insurance-claim-denial-1738690.  

5: Blackman, M. 2021. The link between financial success and patient satisfaction. Medical Economics Journal, vol. 98. URL: https://www.medicaleconomics.com/view/the-link-between-financial-success-and-patient-satisfaction.  

6: Farnen, H. 2023. The financial impact of denied claims in medical billing: bigger than you think. RXNT. URL: https://www.rxnt.com/the-financial-impact-of-denied-claims-in-medical-billing/.