It is often observed that most of the people assume that patient-doctor interaction is one to one interaction. Although the reality is different; visiting a physician is a quite complicated procedure. This procedure consists of a complex system of information flow and payment collection. This interaction is based on a three-party system;
- Healthcare providers; (providers include physicians, hospitals, physical therapists, emergency rooms, out-patient facilities, and other medical services rendered by medical practitioners).
- Payer: it includes health insurance companies or other secondary payers.
Medical billing is the process of translating services provided by healthcare vendors into standard codes (defined by HIPAA act) to prepare claims to obtain payments from health insurance companies for reimbursement.
A Superbill is a detailed receipt of the healthcare services that you provided to your client/patient. The super-bills may include the following information;
- Basic information by the patient; like name, address, phone number, basic information of the healthcare facility e.g. office address.
- Basic information of the provider; it includes the doctor’s name and NPI number.
- ICD-10 codes for the patient’s diagnosis.
- CPT Codes: It includes the list of all codes that correspond to the services you have rendered to your patients.
- Fees: It includes the list of the associated charges for the treatment or the diagnostic services provided by the healthcare practitioners.
- Payment: It involves the list of all payments that are tailor-made towards the services of the physician.
Medical claims are medical bills submitted to health insurance carriers and other insurance providers for services provided to patients by healthcare practitioners. When you visit the doctor, hospital or another provider, your service generates a bill. This bill is then translated into a medical claim to your insurance carrier to process for payment.
The claim contains the demographic information, medical history, insurance coverage and also a report (that contains the information of the procedures performed during the patient’s visit and the reason behind that treatment procedures.
There are different kinds of health insurance plans;
It refers to pay for service insurance. Patients may opt for any insurance provider they like. This insurance plan is comparatively costlier but it is more flexible. Due to the sudden increase in the inflammatory pressure indemnity is becoming less popular.
- Managed care organizations (MCO):
It is a blanket term that includes organizations like Health Maintenance Organizations (HMOs) and preferred provider organizations (PPOs). In this insurance policy patients have fewer options but their premiums and deductibles are fixed and generally lower but it also lowers down health insurance costs for the patients simultaneously.
- Consumer-driven health plans:
It is similar to PPO but it also features a complimentary savings account. These insurance plans have high deductibles and low premiums yet they are increasingly popular insurance plans in the US healthcare marketplace.
Subscribers pay the charges of each insurance plan and health insurance companies to save this subscription amount in the savings account. These savings then are further used to pay the charges of healthcare services that are mentioned in the medical bill before the deductible has been met.
A general clean claim contains the following information;
- What is the information of the patient and what are the services rendered by the healthcare providers?
- Why is the treatment received by the patient?
- Who provided the healthcare service?
- When were the services rendered to the patient by the provider?
- How much the treatment services costs to the patient or their payers?
If this information is accurately mentioned in a claim then the claim is compliant (factually and formally correct claim). This claim ensures the reimbursement and hence, an optimized return on revenue for the healthcare service.