Exploring the Fundamentals of Medical Insurance Billing

1. ExploringtheFundamentalsofMedical InsuranceBilling • Every healthcareorganization should have a clear understandingonhowto proceed withmedical insurance billing. But to do it correctly, it is important to understand what medical claims data means.From thisarticle,youwillfigure itout. • WhatExactlyisaMedicalClaim? • Medicalclaims arethe bills thathealthcareorganizationsaresubmittingto insuranceprovidersof theirpatients.Every medicalbillhas unique medicalcodes.Theyrefer tothe leveloftreatment • offeredtothe patients during their visits. Inother words,medical insurance billing codescaninclude: • Detaileddiagnosisofthehealthcondition • Treatmentproceduresfollowed • Medicaldevicesused • Medicalsuppliesused • Medical transportationused • Pharmaceuticalsprovided

2. When a healthcare provider is submitting a claim to an insurance company, they need to include all the medical codes relevant to the visit. Then the insurance company will be able to evaluate the codesandproceedwithoffering reimbursement. ExploringInformation AvailableWithinaMedicalClaimsFile For every patient encounter, a healthcare organization should open up a medical claims file. It contains confidential information about the patient such as the name, gender, birthday, and address. Thisfile contains twomainparts. They include: • ClaimHeader • Claim headercontainsasummary of the claim. Ithas information related tothe patientasbelow. • Nameofthepatient • Birthday • Residentialaddress • Zipcode • NationalProviderInformation (NPI)forthe servicefacility and attendingphysician • Primarydiagnosiscode • Diagnosisrelatedgroup(DRG) • Inpatientprocedure • Chargefortheclaim • Insurancecompanynameofthepatient. • ClaimDetail • Claim detail is the section where you can find information about the secondary procedures or diagnosisdoneduring thepatientstay. They include: • Procedurecode • Dateofoffering patienttreatment • NationalDrugCode(NDC) • Allcorrespondingdiagnosiscodes • NPInumberofthe attending physician

3. Overallcharge fortheservice LearningAboutMedicalClaimsClearinghouse Medicalclaimsclearinghouse is theelectronic platformthatfacilitatespayors andhealthcare providers.Allthe healthcare providersshouldgoaheadandsubmitmedical insurance billing informationtoa clearinghouse.Then theclearinghouse willstandardizeandscreen allthe medical claims.Thepayorwill getinformationonlyafterthat. One of the main purposes of a clearinghouse is to remove errors during medical coding. It can also reduce thetime thatit willtakeforapatienttoreceivereimbursement. Moreover,itcanbe beneficialfor the payorsaswell.That’s becausethe payors cangetmedical insurance billing records in a standardized format. The payors will not have to do any formatting on their end. They will be abletogoaheadwiththereimbursementswithoutanissue. ReadAlso:-WhatDoes aMedical Billing ExpertDo? UnderstandingtheMedicalInsuranceBilling Process Theoverallmedicalbilling process ismade outof sevenimportantsteps. Allthese stepscapture the overallclaims journeyfromthe momenta patientchecks into a healthcarefacility,untiltheygettheir bill from theinsuranceprovider. Let’s explore thesteps indetail. RegistrationofThePatient The veryfirststepofmedicalinsurancebillingispatientregistration.This iswherethe patient submits his/her personalinformation tothe healthcareprovider. Itincludesinformationabouthealth insuranceaswell. VerificationofInsuranceEligibility Once insurance informationis provided,the healthcare service provider willgoaheadandverifyit. This will ensure that the patient has sufficient coverage for the treatments offered. Moreover, it helps thehealthcare providersto understandallthe policy benefitsthatthe patientis eligiblefor. Itincludesunderstandingwhetherthe patienthas anyout-of-pocket expensesor an accumulatedco- pay.On topofthat,the healthcareprovider can understand whetherthe insurance company ofthe patientrequires apre-authorizationaswell.

4. MedicalCodingInformation • Medical coding is one of the most important pieces of information you can find in a claims request. All healthcare providers should transcribe clinical documentation along with their notes to standard medicalcodes. Below are the mostprominentmedicalcoding systems availableas ofnow: • CurrentProceduralTerminology (CPT) • Diagnosis-relatedGroup(DRG) • InternationalClassificationof Diseases(ICD-10) • HealthcareCommonProcedure Coding System(HCPCS) • NationalDrugCode(NDC) • From these codes, it is possible to explain the medical diagnosis, medical procedure, and even prescriptions offeredtothepatient.Inotherwords,itclearly describeswhatthepatient’soverall conditionisabout. PatientChargeEntry Charge entryreferstothefinalstepbefore thehealthcare providers goaheadandsubmittheir claims. This iswhere they include allthechargesthatthey areexpecting toreceive. ClaimsTransmission Claims transmission would happen once the claims get transferred to the payor from the healthcare provider. This is where the clearinghouse involvement takes place as well. It will review and reformat allinformation beforesubmittingtothe payor.There are situations where thehealthcare providers submittheirclaimsdirectlytothepayorsaswell. AdjudicationofClaims After the payor reviews the medical claim, adjudication will happen. This is where the payor can evaluateclaim anddecidewhether itis valid.The payorwill alsodecide theamounttoreimburse during this stage. Once the claim is accepted, the payor will go ahead and provide reimbursement to thehealthcareprovider. Alongwith that,the payorwill alsocharge remainingamountfromthepatient. Incase the patient doesn’thavesufficient coverage,thepayor candeny theclaim.This is where a patientwillhavetogo aheadandsubmitanappeal.

5. PatientStatement The final step of medical billing is the patient statement. This is where the patient agrees to pay the remaining amount once the insurance company finalizes the claim amount to pay.Now you are aware of the medical claims process and how it works. It will help you to go ahead and submit claims forinsuranceclaimswithoutany majorissues.