Tuesday, April 2, 2024

What are medical claims?

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What are medical claims, and what do you need to know

Medical claims are the most critical data sources for healthcare businesses. For each billable patient visit, all-payer claims include complete diagnostic and procedure information. This claims healthcare organizations may use data to track referral trends, improve healthcare quality, boost sales, and enhance their go-to-market strategy.

All of this can be difficult to accomplish without a thorough familiarity with medical claims data. If you do not work in the medical sector, the medical insurance claims procedure might be highly complicated. However, it is critical to understand the processes a claim takes to know what to expect and how to deal with any difficulties.

medical claim

Today in this article, we are going to discuss what is meant by medical claims, how to file medical clam, the steps of the medical claim process, and so on. So here we go.

What is the medical claim?

A medical claim is a reimbursement request sent by your healthcare provider to your health insurance company. It outlines the services provided. And it guarantees that the doctor is paid, that your insurance covers the covered benefits that you are invoiced for the remaining. A claim is initiated the moment a patient arrives for an appointment. It tracks a health service from its inception till the patient gets and pays the final bill.

In the case that the patient visits a doctor who is not in their network, claims might be submitted by the patient. However, claims are immediately sent to insurance by the healthcare practitioner following an appointment or other service in most cases. You may be confident that claims processing centers follow strict HIPAA rules to protect the safety and security of specific sensitive data.

Medical claims are made up of codes, usually Current Procedural Terminology (CPT) codes that define the medical services that you delivered to the patient. The medical codes define any service provided by a provider, such as:

  • A diagnosis
  • Medical supplies
  • Medical instruments
  • Transportation for medical purposes
  •  Pharmaceuticals as well as

How do medical claims work?

Following a patient contact, your practice is required to convert the services you delivered into CPT codes. These codes define the services described above that are routinely administered. Without them, medical claims would frequently consist of long practitioner explanations of delivered services, introducing inconsistencies. Rather, CPT codes allow payers to quickly assess the services you performed and whether the patient is insured.

Medical claims should also reflect the fees charged by your organization for each classified service. CPT codes do not affect what you may and cannot charge for your services – that is entirely up to you. The final question is whether the patient’s gains will result in the provider completely reimbursing you or delaying part – or all – of the patient’s payment to you.

How to file a claim on your own

More frequently than not, healthcare providers will transmit the claims to be handled directly. Following service, the physician’s practice will collect your claim, together with any pertinent information from any insurance paperwork you filled out, as well as the medical codes, and submit it to a claims processing department or third-party administration.

The insurance company will process your claim form, and you will be billed for any leftover costs after insurance coverage and physicians’ fees have been paid. If you see a physician, not in your network, you will almost certainly have to file a claim on your own. In that instance, the stages are as follows:

  • Use the appropriate claim form for your benefit plan. You may locate it by checking in with your insurance information on your insurance website.
  • If you complete it by hand, be sure your handwriting is legible and that you fill in the blanks correctly. However, you may complete this form online.
  • Include any required information, such as the date of service and medical codes obtained from your physician’s office.
  • Verify the time limit for submitting your claim following services, and be sure to do it before the deadline.
  •  Check to see if your insurance covers the treatments you had. If this is not the case, your claim will reject.
  •  Include a signed pre-approval form with your claim submission if necessary.

 What happens once you create a claim?

Once your claims are created, it is good to run them through claim scrubbers to catch any mistakes. Without this mistake detection, you may submit incorrect claims, resulting in payer rejections that necessitate resubmission. In addition, resending a claim adds to the workload of your administrative personnel and delays refunds, reducing revenue and cash flow.

The majority of claim scrubbers are automated systems provided by third-party medical billing firms. They’re frequently a part of clearinghouses, which are places where claims are finalized between the time you submit them and the time payers receive the bill. Technically, you can delegate claim scrubbing to your administrator, but the intricacy of CPT codes makes automation more trustworthy.

What exactly is a medical claims clearinghouse?

A medical claims clearinghouse acts as an electronic link between healthcare professionals and service users. Medical claims are transmitted to a clearinghouse by healthcare providers. Clearinghouses then process, standardize, and filter medical claims before delivering them to the payer.

This procedure aids in the reduction of medical coding mistakes and the shortening of the time it takes to get provider payment. If a claim has medical coding or medical billing errors or fails to fulfill formatting standards, the payer may reject it. This implies that the claim will be resubmitted, causing provider compensation to be delayed.

What are the claims processing steps?

To guarantee accuracy and acceptance, healthcare claims are processed through some procedures. The path of a claim begins even before you arrange an appointment. Because insurance does not always cover all treatments or procedures, it is critical to review your health insurance policy to see what is covered and where to go for in-network care.

You call and make an appointment after you know what is covered and have found a doctor. Almost shortly after you receive your care, your claim is processed. Following an appointment, the following are the processes a claim will go through until you receive a final bill.

  • Insurance receives a bill for service charges, excluding any co-pays made at the time of check-in.
  • A qualified claims processor will evaluate the claim, confirming the accuracy and comparing it to the insurance plan to determine whether or not the services given were covered by insurance.
  •  If the services obtained were covered by benefits, the insurance company will pay the claim in accordance with the policies. Based on your plan, they will pay the whole claim in full; else, the remaining balance will be invoiced to you, the patient.
  • Payments will be verified and added to your insurance plan’s coverage and out-of-pocket totals. 
  • Benefits are explained, detailing the services received, how much was covered by insurance, how much the providers paid, and how much remains to be invoiced.
  • You will be issued a final bill to pay.
  • Check the EOB and final bill before settling the claim to confirm everything is proper and billed appropriately. Balances do not always match due to a mismatched process code or another clerical error. Claims can be amended and corrected at no cost to you.

What happens if your claim is rejected?

An insurance claim may be declined for various reasons; however, just because it was declined does not imply it cannot be resolved. If you get a claim rejection notification, contact the relevant billing provider to discuss the reasons for the decision. Here are some of the most typical causes for claim denial.

  • The erroneous claim forms were delivered or completed improperly.
  • Treatments were administered to the patient without prior authorization.
  • Insurance does not cover the service since the claim was submitted too late.
  • Medically unnecessary services were provided.

If such are the reasons a claim was refused, try to settle it over the phone. If a claim cannot be settled, it might be sent to the insurance provider for official evaluation. They can examine the claim in further depth. They will then either reverse the decision or decide that the claim may be resubmitted with the necessary facts to be accepted.




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I am a medical biller, a blogger and have 20 years of experience in medical billing, medical billing management, and medical assistant. My background includes positions as a clinical medical assistant, medical records technician, medical office manager, biller, and coder. I am certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) and by the Practice Management Institute (PMI) as a Certified Medical Office Manager (CMOM). As an office manager/biller/coder, I was a member of the Michigan Medical Group Managers, Michigan Medical Billers Association. I also served as a committee member of the Michigan Osteopathic Association of Practice Managers Education Committee.

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