The Intricacies of Medical Billing

Medical bills in the USA are reimbursed by the insurance companies after the healthcare providers file claims regarding the services provided.

The medical billers are employed by healthcare organizations to conduct meetings with physicians and patients to ensure that the claim’s validity and then follow up with the insurance companies to prevent them from writhing out of the claim for any petty reason.

The medical billing and management services provided by billing companies are a crucial part of the revenue cycle of hospitals and healthcare service organizations. A good medical biller will also bring in profits by applying their knowledge at the right time and place.

The reason behind billing

The check-up and diagnosis presented by the doctor at the clinic or hospital are a little more complex than the one-on-one interaction the patient has with the doctor. The insured patient is a part of a three-party interaction when they visit the doctor for medical services.

The first position is the patient and the second is the healthcare provider. The healthcare service provider includes a plethora of physicians, hospitals, therapists, emergency rooms, doctors, outpatient services, and other medical services. The third party includes the list of insurance companies.

The medical biller has to do the important job of bridging the gap between the 3 parties. Most hospitals outsource medical billing services to nationally certified coders and billers with deep knowledge of the various medical procedures and their diagnosis.

The healthcare provider must be reimbursed by the patient and the insurance company and this is ensured by the biller. The billing is necessary because many times insurance claims are denied and this leads to payment problems which cause the hospital a loss.

The procedure followed by the biller is the collection of data present in a superbill which has the patient and his/her procedure which is compiled together to form a claim for the insurance company.

The patient’s demographic information, insurance coverage, medical history and a report of medical diagnosis and surgeries are filed and sent to the insurance company.

The insurance process

Health insurance is considered as the insurance or reimbursement for medical expenses. The subscribers or insurance customers have to pay a fee or amount that protects them against medical expenditure. Healthcare insurance has various types-
  1. Managed care organizations-This is an umbrella term for Healthcare Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) and this category provides lesser flexibility to customers. They have a restriction on the number of providers they can consult, and their premiums are fixed at a lower rate.
  2. Indemnity-The patient can choose their providers as required for this pay-for-service type of insurance. The grants provided to the customer are more flexible and the cost of insurance is costly. Indemnity insurance is losing popularity as the prices of healthcare increase.
  3. Consumer-driven healthcare plans-CDHPs or High Deductible Health Plans (HDHPs) are plans that deduct money from health savings accounts and health reimbursement accounts so that payments for healthcare expenses can be made. This includes high deductibles and lower premiums.

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