Here’s the lay of land about what goes into processing medical claims
Are you a student studying to become a medical billing and coding specialist, or considering this career field? If so, you may already have a basic understanding of the medical billing process through your own experience with the system as a patient. However, it can be helpful to gain a broader understanding of the industry as you learn about the specific functions of this important healthcare role.
If you work as a health claims specialist, you will likely work for a doctor’s office, nursing home, hospital, or other healthcare facility. You will handle submitting health claims to the insurance companies in order to reimburse your office for the services provided to patients. Read on to find out more about what the process involves, and what kinds of insurance you are likely to encounter in this work.
The process of medical billing
Each patient visit to a healthcare practitioner triggers a similar procedure in terms of the billing process. The medical billing specialist has responsibilities at each stage:
1. Checking in a patient
One of the duties of the medical biller and coder is to gather demographic information about each patient who will use insurance to cover at least a portion of his or her services. This information can include the name of the insurance policy and member number, as well as any contact information that processing forms might require.
2. Verifying insurance
The health claims specialist will confirm during every patient visit that the coverage information on file is up to date.
3. Obtaining authorizations
The health claims specialist can help to confirm the patient’s benefit coverage, as well as determine whether any authorizations will be necessary for certain procedures.
4. Entering information
Depending on what services the patient receives during a visit, the medical billing specialist will enter that information, as appropriate, into patient records.
5. Coding the claim
Part of this work is knowing what medical codes correspond to the particular diagnosis or procedure a patient received. These codes indicate to the insurance company how to process the claim. This may require some research, either in following up with a physician or nurse for clarification, or using coding manuals, apps, or software to determine the appropriate code.
6. Submitting the claim
Because these health professionals must interact with a number of different insurance companies, it is important to maintain careful records about what each company requires, so that the submission is complete and accurate each time.
7. Confirming payment
Within a certain time frame of submitting the claim, the billing specialist will confirm that payment has been made. This can require follow-up should any payments be delayed.
The basics about health insurance plans
In order to communicate with patients about their coverage, medical billing specialists need to understand the different kinds of health insurance plans that are available. This knowledge also makes it easier to interact with individuals at insurance companies, should the need arise to resolve issues regarding a particular claim.
Types of health insurance plans:
- managed care plans, which coordinate networks of caregivers and hospitals, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point-of-Service (POS) plans, and Exclusive Provider Organizations (EPOs)
- fee-for-service (FFS) plans, also known as Indemnity Insurance
Types of government plans:
- Medicare (for those over 65 or with a permanent disability)
- Medicaid (for low-income individuals or families), which each state regulates individually
- Veterans’ programs, such as TRICARE and CHAMPVA
There are strict guidelines pertaining to these government programs, and it will be important for a medical billing specialist to understand how to navigate what can be complex processes for each one.
We hope that this overview provides useful context to the world of medical billing. If this profession intrigues you, and supporting a healthcare provider in this way seems like good fit for your skills and interests, look for a career training program like the one at Salter School. It could be the beginning of a new phase of your professional life!
This article is part of the Salter School’s weekly blog. We offer a number of professional training programs at our campuses in Malden and Fall River, MA. Reach out to us today for more information or to schedule a campus tour.