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Medical Claims 101: Medical Claims Processing

It is important to note that the health care system is a multi-billion market, with millions of people depending on specialized professionals whose primary responsibility is to ensure that medical care facilities, pharmaceutical companies, pharmacies and medical equipment manufacturers are following the law and policies governing health care system operations, products and services. One of the systems involved in the health care industry is medical claims processing. Medical claims processing deals with the interaction of health care providers and medical insurance agencies. In order to understand medical billing and coding, it is important to discuss the relationship between health care providers, policy holders and health insurance companies first.

Health care providers are private clinics, hospitals, pharmacies, dental clinics, nursing homes, assisted living facility, in-home caretakers and chiropractor, where a patient receives and is billed for health products and services. On the other hand, insurance companies are the ones providing medical subsidies for qualified patients or policy holders. Insurance policies are different from one company to another and many people have insurance coverage obtained privately, from an employer or from the government. Insurance companies operate under the same business operation wherein a policy holder pays a certain amount of money monthly or annually to the insurance agency, which is termed as premium. The coverage of the insurance policy dictates if an insurance companies would pay the medical expenses in full or partially involving a policy holder’s hospitalization, medical operation or medical procedure such as diagnostics and medicines and other medical supplies used. The individual who purchases a health insurance is called a policy holder, such as a young adult for example, finding a basic insurance coverage to pay all medical expenses more than the deductible, wherein the amount is pre-arranged and should be paid before the health insurance coverage sets in.

In medical claims processing, it is initiated by a policy holder who is seeking medical intervention or health care services such as medical consultation laboratory or any diagnostic procedure, surgery or hospitalization. And after the policy holder receives the medical intervention, he is then financially responsible to pay the deductible, for which the amount of money that he agrees to pay before the insurance coverage begins. Once the policy holder provides his insurance details to the health care provider, then the transaction is complete, after all the verification is done. After which, the transaction between the insurance company and the health care provider begins. Health care providers records all medical transactions and send them to medical coders and billers for the details of a medical claim, and afterwards forward the medical claim to the policy holder’s insurance company. Upon receiving the claim, an insurance company will review the claim and either accept or decline the claim basing on some factors such as the correctness or accuracy of information provided and the coverage plan the policy holder have obtained.Short Course on Software – What You Should Know

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