The Process of Medical Claims and Insurance.

Medical billers ensure that the payment cycle between the insurance company, healthcare service provider, and the patient. The major task to be performed by a medical biller is to collect billing information based on conversations with physicians and patients and understanding their history so that they can draft a strong claim for insurance that cannot be denied. The medical biller is responsible for obtaining the payment that is due to the healthcare provider from the insurance company and the patient. The data collected by the biller includes patient demographics, medical history, reports on the surgeries conducted and their requirements, and insurance coverage bought by the patient. The medical billing companies in USA are hired by healthcare providers to amicably derive the payments required.

What are claims?

  1. Claims created by medical billers are similar to the claims generated by medical coders. The medical billers extrapolate the codes that have been assigned by medical coders in accordance with federal mandates and compliance for a particular prognosis or diagnosis and then use these codes to make the iron-clad claims.
  2. The insurance payer becomes aware of the healthcare service provided through the claims which contain procedure codes such as Current Procedure Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS). The medical necessity is determined from the diagnosis codes and surgery codes which are documented using ICD codes.
  3. The cost of the procedure, information about the patient’s visit and details about the patient are compiled by the medical biller.
  4. The claim has to be a complaint and that is checked by the medical billing management services employed by the hospital. The claim has to be factually correct and essentially be valid in all forms. This makes the scenario complicated and the biller must be sure of the claim allowance which is evaluated and informed to the payer. The claim is then returned to the biller with the payment that is due which is then deducted and sent to the patient for the balance payment.

What is insurance?

  1. Health insurance protects the patient from medical expenses. Some part of the expenditure is paid by the insurance company and some of it is paid by the patient. This is called co-payment. Thus it is important for customers to select insurance companies that give the best coverage.
  2. Indemnity is the least popular insurance type in the face of rising healthcare costs. The patient can choose their own service provider but this makes the insurance premium costly. It offers a higher level of flexibility to the patient in terms of grants.
  3. Managed Care Organizations have become the most popular insurance type. It includes organizations such as Preferred Provider Organizations and Healthcare Maintenance Organizations. The customer has restrictions such as the kind of service provider they can visit and the premiums and deductibles are fixed. However, the cost of having a health insurance is reduced even if the options are lesser.
  4. Consumer Driven Health Plans These are also called High Deductible Health Plans which deduct money from the health account of the consumer.
Posted in health.


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