Why No One Talks About Insurance Anymore

Medical Claims 101: Medical Claims Processing

Take note that the health care system is a multi-billion industry, with millions of people relying on specialized professionals whose responsibility is to ensure that the operations of medical care facilities, pharmaceutical companies, pharmacies and medical equipment manufacturers are following the law and policies governing people’s health. Medical claims processing is one of the systems involved in the health care system. Medical claims processing involves the interaction of the two most important aspects of the health care system which are the medical insurance companies and health care providers. It is important to discuss the relationship between health care providers, policy holders and health insurance companies first before understanding how medical billing and coding works.

Health care providers are facilities or practices where a patient receives and are billed for a product or service, that include private clinics, hospitals, pharmacies, nursing homes, assisted living facility, in-home caretakers and chiropractor. 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. The process involving how insurance companies work follows the same business operation, wherein a policy holder pays a certain amount of money to the insurance company either monthly or annually, which is known 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. The policy holder provides their insurance details to the health care provider and the transaction between the health care provider and the policy holder ends. After which, the transaction between the insurance company and the health care provider begins. The health care provider will ensure that all medical records are included in the medical claim or dental claim processing, and medical coders and billers are the ones responsible for creating this medical records, and they are the ones who send these claims 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.
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