Medical claims processing can be straightforward to complex process, depending on the circumstances. Typically, a medical billing insurance claim process would start when a healthcare provider or practice provides treatment to a patient and then sends the bill of services to the designated payer. This designated payer is usually the patient’s health insurance company. The payer will then evaluate the claim based on their set standards along with different determining factors in order to verify services that it will reimburse.
Medical claims processing only becomes complex when there are complications in the claim, such as insufficient coverage or the failure of a patient to stay current with dues. In a perfect world, the steps to a medical billing procedure are quite simple:
- The patient receives a medical service from a licensed provider
- The services are recorded and assigned the appropriate codes by a medical coder
- ICD codes are to diagnoses as CPT codes are to treatments.
- A summary of services rendered is generated through the entered code sets, which in turn makes up the bill.
- The patient demographic data along with his or her insurance information are then added to the bill; and
- The claim is now ready for processing.
Medical claims processing can be done either electronically or manually. Various technical protocols as well as industry standards must then be followed so that insurance claims can be delivered accurately and expediently between the payer or the insurance provider and the medical practice. Different medical billing services use various approaches to medical claims processing. Others may use the manual or paper route, while more modern service providers do everything electronically with the help of increasingly reliable software programs and applications. Today’s healthcare providers as well as insurance companies subscribe to electronic claim systems as they offer faster and more accurate, (sometimes even cheaper) processing than traditional manual methods.