Medical Claims Processing

Written by Kimberly Clark
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Initially one might think that processing medical claims is a rather simple and mundane task. However, when you take into account all the systems of diagnosis and procedural codes that must be properly encoded on the claims and the compliance regulations that govern claims submission, you quickly see that it is not as easy as one might think. In fact, the complexity of preparing and processing medical claims has given birth to a very lucrative industry.

The federal and commercial healthcare insurance companies are constantly making the rules for submitting a medical claim stricter and stricter. Doctors want to focus their attention on their patients' care, not on keeping themselves well versed in the latest guidelines for claims submissions. This is especially true when a competent medical claims processor can do it for them.

Process of Preparing Medical Claims

The process of preparing a medical claim involves several steps. First of all, the patient's payer information must be collected. The payer is the healthcare entity that the claim with be submitted to and is responsible for paying the bill on the patient's behalf, some examples of payers are Medicare, private healthcare insurance companies, and health maintenance organizations (HMO). In some instances, a patient will have more than one payer.

Then the doctor's diagnosis, plus the procedures he performed and the treatments he prescribed, must all be itemized on the claim. This line item listing should conform to the healthcare industry's standard coding system, which references the ICD-9 (International Classifications of Diseases 9th Edition) for diagnosis codes and CPT-4 (Current Procedural Terminology, 4th Edition) for procedure and treatment codes. In addition, the services must be laid out by time and date received.

The medical claim is now ready for submission to the healthcare payer. If submitted to a government payer like Medicare, the claim must be transmitted electronically, in a HIPAA (Health Insurance Portability & Accountability Act of 1996) compliant format. Medicare says that only about half the claims that it receives are in an acceptable format, which means most medical claims will require resubmission. Having a comprehensive software program can automate this process and prevent billing mistakes and claims errors.


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