So you’re a doctor, and between seeing patients, managing staff, and keeping up with continuing education, the last thing you want to deal with is the hassle of claims adjudication. But the reality is, to get paid for the important work you do, you have to play the game. The good news is, once you understand the rules, claims adjudication doesn’t have to be complicated or stressful. This guide will walk you through everything you need to know to get your claims processed efficiently and maximize your reimbursement. You didn’t spend over a decade in school to become an expert in medical billing, so let us handle that part. By the end, you’ll feel confident in your knowledge of billing guidelines and ready to work with your practice administrator or billing service to put an efficient claims process in place. Your patients need you to focus on them—let us focus on the rest.

What Is Claims Adjudication in Healthcare?

Claims adjudication is the process of reviewing and evaluating insurance claims to determine appropriate payment. For medical practices, claims adjudication typically involves a billing company reviewing claims submitted to insurance companies on your behalf to ensure maximum and appropriate reimbursement.

As a physician, claims adjudication impacts you and your practice in a big way. Accurate claims adjudication means you get paid properly and on time for the services you provide. Inaccurate or delayed claims adjudication can lead to loss of revenue and hassles spent following up on unpaid claims.

A medical billing company will handle the claims adjudication process for you. First, they review the details of the insurance claim for accuracy and completeness before submitting to the insurance company. They verify things like correct procedure and diagnosis codes, patient details, and provider information. Any errors found are corrected before submission.

Once the claim is submitted, the insurance company also reviews it to determine appropriate payment. The billing company regularly checks the status of claims to ensure there are no issues preventing payment. They will work to address any questions or requests for additional information from the insurance company as quickly as possible.

Proper claims adjudication, whether done in-house or outsourced to a billing company, is essential to a well-run medical practice. Outsourcing to a reputable billing company allows you and your staff to focus on patients while still getting maximum and timely insurance reimbursement. When evaluating options, look for a company with experience in claims adjudication for physicians that offers services like insurance claim review, submission, follow-up, denial management, and appeals. With the right partner handling your claims adjudication, you can have peace of mind knowing you’ll be paid properly for the important work you do.

Common Reasons Claims Are Denied

As a doctor, nothing is more frustrating than having claims denied. Unfortunately, it happens all too often. Here are some of the most common reasons your claims may be getting rejected.

Missing Information

The #1 reason claims are denied is because key information is missing. Things like patient names, dates of service, billing codes, and more. Double check that all fields on your claims are filled in properly before submitting.

Incorrect Coding

Using outdated billing codes or codes that don’t accurately reflect the services provided is another common mistake. Make sure your practice stays up to date with the current CPT, HCPCS and ICD-10 codes and that everyone on your staff is well-trained on proper coding procedures.

Medical Necessity Issues

Insurance companies want to see clear evidence that the services billed were medically necessary for the patient. Be extremely detailed in your notes and include things like symptoms, diagnosis, treatment plan and patient health history. The more information you provide, the less likely payers will be to dispute medical necessity.

Authorization Problems

Some services require preauthorization from the insurance company before billing. Failure to obtain proper authorization, or authorization that has expired, will result in denied claims. Check with each payer about their specific authorization rules to avoid this issue.

By paying close attention to details, using the right codes, providing comprehensive notes, and getting proper authorizations, you can reduce the number of claims denials and ensure you get paid for the important work you do. Stay on top of the ever-changing rules and don’t hesitate to appeal denied claims that you believe were billed properly. With diligence and persistence, you can get your claims adjudicated fairly.

Appealing a Denied Claim: What Physicians Need to Know

Appealing a denied insurance claim can be frustrating, but as a physician, you need to advocate for your patients and your practice. Here are some steps you can take to appeal a denied claim:

File An Appeal Immediately

Don’t delay appeal the decision as soon as possible, within the timeline stated in the denial letter. Most insurance companies allow 30 to 180 days to file an appeal. Gather all supporting documentation about the claim, including notes from the patient visit, test results, correspondence with the insurance company, and a letter from you explaining why you believe the claim should be paid.

Call the Insurance Company

Speaking to a real person about the denial can be very effective. Call the insurance company and ask to speak to an appeals specialist. Explain the situation, provide additional details about the patient’s condition and treatment, and request that the claim be reprocessed. Take detailed notes about who you spoke to and what was discussed. Follow up with a written appeal letter referencing your phone conversation.

Consider A Peer-to-Peer Review

For complex claim denials, you may request an independent peer-to-peer review with the insurance company’s medical director. Be prepared to discuss the case in detail and have all medical records on hand to justify your treatment decisions. A peer-to-peer review allows for an open conversation between physicians and often results in the claim being approved.

File A Complaint

If appeals and peer-to-peer reviews are unsuccessful, you may need to file a complaint with your state insurance regulator about unfair claim practices. Most regulators have complaint processes in place specifically for health insurance issues. Provide details about the denial, your attempts to appeal, and how the insurance company failed to properly evaluate the claim. Regulators can investigate and may issue fines or require the claim to be reprocessed.

Take Legal Action (if necessary)

As a last resort, you may need to pursue legal counsel regarding the denied claim. Law firms that specialize in insurance litigation may file a lawsuit against the insurance company on your behalf to recover payment for services rendered to your patient. Going to court is a serious step, but may be necessary to dispute unfair denials that remain unresolved through other means.

Finding the Right Medical Billing Company for Your Practice

Finding the right medical billing company is crucial to ensuring your practice’s financial health. With so many options out there, how do you choose? Here are some tips to help you find a medical billing service that’s the perfect fit.

Look for experience

See if the company has experience with billing for your specialty. The needs of a primary care practice differ from an orthopaedic practice, for example. Ask if they have experience with your Practice Management System and Electronic Health Records platforms. Experience means they’ll get up to speed quickly and understand the nuances of your workflow.

Check their technology

A reputable company will use a robust billing and coding software to help maximize your reimbursements. Ask about their approach to denial management and how they stay on top of ever-changing payer rules. See if they offer portal access so you can view reports and key metrics anytime.

Evaluate their services

At a minimum, the company should handle claims submission, payment posting, denial appeals, and patient billing. But you’ll want a full suite of revenue cycle management services. Ask if they provide credentialing support, insurance verifications, coding audits, and patient satisfaction surveys. The more comprehensive their offering, the less headache for your staff.

Ask about their team

Don’t underestimate the importance of the people behind the technology. Ask about the experience and certification of their billers and coders. Are staffing levels adequate to provide high-touch service? Is there a dedicated account manager to oversee your account? Meeting some of the team beforehand is ideal.

Compare costs

While fees will vary based on the size and complexity of your practice, look for a fair and transparent pricing structure with no hidden costs. Some companies charge a percentage of collections, while others charge a flat monthly fee. Make sure you understand all costs before signing a contract.

The keys to finding a great medical billing partner are experience, technology, service, people, and fair pricing. Do your due diligence, check references, and go with the company that you feel will be the most vested in your success. With the right fit, you’ll gain peace of mind and be able to focus on your patients.


So there you have it, doc, the inside scoop on how claims get processed and paid. It may seem like a mundane part of the healthcare business, but understanding the ins and outs of claims adjudication will make you a savvier practitioner. You’ll know what documentation and codes to provide to get your claims approved quickly, and you’ll understand why some claims get denied so you can avoid those issues in the future. Most importantly, you’ll see that while payers and administrators have a process to follow, you as the physician still have an important voice in that process. Speak up if you see claims that should have been paid or patients who deserve more. Your patients are counting on you, and now you have another tool in your arsenal to provide them the best care. Claims adjudication may not be the most glamorous part of your job, but take heart – it’s one more way you get to be their hero.