Billing and Coding for Health Services - Research Paper Example

Billing and Coding for Health Services Affiliation Billing and Coding for Health Services Medical billing defines the process of ensuring that payment is received for the claims that are placed with health insurance companies, to ensure the receipt of payment for the medical services that are provided to a patient by a healthcare professional. Many insurance companies, both public and private insurers, are observed to apply a similar process. There are certification schools that have been set up to ensure that health care providers are equipped with the skills demanded by the medical billing field.

The medical billing process defines the interaction that is observed between the insurance company and the medical service provider. The interaction is described as the revenue cycle management, which is noted to take a varying amount of time to complete. Medical healthcare providers are observed to contract the healthcare services rendered with a variety of insurance companies. However, the interaction commences after the patient is treated by a physician. There is a trend towards the outsourcing of billing and coding services through the Group purchasing organizations (Reese, 2014).

This has been noted to lead to significant reductions in cost. However, there is a growing need to make the billing process clearer to the patients.The codes that are defined in the diagnosis procedures are employed by the insurance companies in the examination of the medical necessity and the coverage. After the determination of the medical procedures and diagnosis, the medical biller is demanded to communicate the claim to the insurance company. Usually, medical healthcare providers utilize electronic transmission, such as electronic data interchange, to communicate the claim to the payer directly.

It is integral to note that the insurance company defines the payer; thus, the insurance companies use medical claim adjusters or medical claims examiners to process the claims that are submitted. In the case of great dollar amount claims, the insurance companies examine the claim and value the validity for the eligibility of the payment via rubrics defining patient eligibility, the healthcare service provider’s credentials and the medical necessity of the claim. The approved applications are refunded for an agreed percentage that is negotiated between the insurance companies and the healthcare service providers.

However, the failed claims must be communicated to the provider using an Electronic Remittance Advice (ERA).There is a difference between the rejected and denied claims; however, there is a common mistake of interchanging the terms. Denied claims define a processed claim that has been classified as unpayable. There is an allowance provided for the appeal for reconsideration of denied claims. On the other hand, rejected claims define claims that cannot be processed by the insurer as a result of the provision of corrupt information to the insurer.

Rejected claims do not demand appeal, but they must be reviewed, modified and returned to the insurer for examination. Medical billing regulations are noted to define a complex and dynamic process. For this reason, it is integral to ensure that the healthcare service providers are updated on policy changes regarding medical billing and coding for the provision of medical services. The primary role of the process is the provision of maximum insurance payments through the proper examination of the provider’s claims.

As a result, the medical billing professionals are tasked with ensuring the minimal denial of the claims presented to the insurance companies. ReferenceReese, C. (2014). Realizing Affordable Healthcare: The Advent of Medical Billing - Fiscal Today. Fiscal Today. Retrieved 7 February 2015, from http://fiscaltoday.com/realizing-affordable-healthcare-advent-medical-billing/