A medical claim refers to the itemized statement of services and costs from a health care provider or facility that is submitted to the insured for payment. In Medical Billing and Coding parlance, claims processing is the overall activities and work which involve submitting and following up on the claims.
Coding claims lead to converting physician and/or specialist performed services into revenue.
Here is the general process of claims submission:
- On arrival, the patient would hand over the insurance card and fill out a demographic form. This form covers essential information including the patient name, date of birth, address, Social Security Number and details and/or Driver’s license details, name of the policy holder and other relevant information.
- The patient presents a government issued photo identity for verification purposes regarding the policy. It is important to note that presenting someone else’s insurance papers and/or submitting a claim that misrepresents a medical situation is equivalent to committing a fraud. The responsibility of verifying patient identity is the liability of the provider.
- Following the above paperwork and other required processes from the end of the service provider, the patient is encountered by the physician/ specialist/ other medical service provider.
- The examination and/or other service provided is documented and the billable services mentioned clearly.
- The medical coder then puts together the billable codes. This is based on the physician’s documentation.
- Following the above, the coding is reached to the biller who then enters information into the correct and appropriate claim form in the billing software.
- The said software then may send the claim directly to the payer or to the insurance company/ clearinghouse which does the needful.
A medical claims processor works directly with with the doctor’s patients and insurance companies to ensure that payment for services come through.
Skills which are required for this profile are
- A good knowledge base of the health insurance industry
- Positively clear communication skills
- A thorough understanding of health coding and medical terminology
- Excellent attention to detail
It is imperative that while submitting or processing claims, all bills, details and papers are in place. This saves the patient and the health care facility a lot of hassle. For new patients, obtain information about coverage when they book their first appointment. This gives you more than enough time to process it. Keep a copy of the patient’s insurance card and review details on each visit. Review eligibility and work with the patient on ensuring a healthy insurance track record.
The medical claims processor goes a long way to make the patient’s relationship with the health service provider a strong and long lasting one. And this translates to better revenue for the provider.
Claims, must thus be handled with care.