Everyone hears about the fact that much of the cost of healthcare is driven by the expense of processing and adjudicating claims. What is often not mentioned is what is truly at the root of these expenses - payers that are attempting to withhold from physicians the money they are due.

The tactics used by payers to save money (and drive up the cost for medical practices to operate a medical billing process) include: Underpaying over 10% of medical claims, "losing" submitted claims on a regular basis, and constantly changing the rules by which they decide if claims are actually payable. If the provider's medical billing process is not technology savvy, well designed and properly staffed then over 20% of the practice's revenue can easily be lost to these tactics.

Payers have strong incentives to utilize these tactics to lower their costs. More than 50% of the claims that are underpaid or lost by payers are never pursued by physicians and facilities. Since the payers can save significant money by losing claims and accidently underpaying they have strong motivation to make the billing process difficult.

Here is another shocking fact - it costs the average insurance company about $25 each time a representative has to get on the phone and discuss a lost or underpaid claim with a medical billing specialist. A final key fact is that most payers "grade" each provider. The lower a provider's grade (i.e., a D versus an A) the more likely the payers are to lose or under pay the provider's claims. Why? Because these providers have no track record of catching these problems and pursuing them.

As soon as payers see the economic motivation of losing and underpaying claims disappear, they will be forced to adopt acclaim adjudication process that is easier and cost significantly less for medical providers. The way to make this happen is to ensure that each provider is rated an A. This is why improved medical billing processes are a key weapon in the fight against rising healthcare costs.

If the medical practices and medical billing services dig in and fight for the last dollar on every claim they will quickly force the insurance payers to adjust their internal processes. With each claim paying in full and their staff inundated with billing specialist asking why a claim was lost or underpaid, the payers will see rapidly shrinking profits that will force them to acknowledge that the costs of the games they play are no longer justified by the savings form unpaid claims.

Many companies and individuals are dreaming of the day when the medical billing process disappears entirely and claims are adjudicated in real-time while the patient is standing at the checkout desk. In this system significant costs will be saved, but the system will never emerge until payers no longer have an incentive to play games with medical claims. Medical billing companies and medical providers can make this happen by insuring that all providers are rated A in the eyes of each payer.

Copyright 2008 by Carl Mays II