Processing of insurance claims

Health Insurance

There are several steps in the insurance claim process. Many patients have some form of health care insurance. Health insurance is, more or less, payment made by the patient to the insurance company to guard against ailments. The insurance company pays out for medical treatment. In many cases, the patient will have some sort of co-pay, which is when they must pay a deductible or otherwise some portion of the total cost, and the insurance company covering amounts over the copay.

Green & Rowell (2013, Chapter 4) notes that "the processing of an insurance claim is initiated when the patient contacts a healthcare provider's office and schedules an appointment." When the patient visits the office, he or she must fill out the CMS-1500 claim form, which is the common form for making an insurance claim in health care. This form will contain the information needed for the health care provider to file the claim and collect payment. This information includes the patient's name, the information pertaining to their insurance policy, the different codes for the charges and diagnoses so that the insurance company knows what it is paying out for (Green & Rowell, 2013, Chapter 4).

There are different ways of looking at the payment. For example, "accept assignment" is a place on the form that indicates that the medical care provider will accept what the insurance company allows for the payment, leaving the patient to cover the rest by other means. The medical care provider will often know what the insurance company covers, at least for routine items. One of the next steps is to determine the out-of-pocket provision. This is a provision that holds that a patient is only responsible (Green & Rowell, 2013, Chapter 4). The text mentions pre-existing conditions but it is unclear whether this applies now that the ACA has kicked in.

Once the form has been filed with the insurance company, it becomes an account receivable for accounting purposes. The medical care provider will therefore need to collect from the insurance company the payment for the procedure. The filing of the form incorporates several steps. First, the health insurance specialist will fill out the form, ensuring that it is entirely accurate, as an inaccurate form may be rejected. Proofreading of insurance forms is imperative to facilitate efficient payment (Green & Rowell, 2013, Chapter 4).

So as highlighted, the first step is to make the appointment. The second step is to verify the patient's information. The third step is then to collect the co-payment. The fourth step is to produce the form from the patient's visit that will be required to file for the insurance claim. Included in this will be codes for all items and procedures billed, all account information and then to submit the form to the insurance company. The payment can then be posted to the patient's account (Green & Rowell, 2013, Chapter 4).

The completed claim should then be signed by the provider and copies produced so that all parties have a record of this. The claim then needs to be logged with the insurance registry. There are then four more stages to the claims life cycle. First is the claims submission and electronic data interchange. Second is claims processing. So at this point the claims information has been sent to the insurance company, which is now verifying the information and processing the claim (Green & Rowell, 2013, Chapter 4).