Billing Process for an Inpatient

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Table of Contents

Introduction
Claim submission
Verification of medical claims
Claim encoding
Claim Verification
Claim Payment
Conclusion
References

Introduction

Healthcare is vital to all because when people are not healthy they can not be productive, hence healthcare systems ensure when somebody gets ill he/she can access the medical facilities. When someone joins a healthcare system the contributions are made monthly. Hospitals keep records of all their patients and information explains the age, gender, contacts, and occupation of the patient and also a summary of the patient’s history. When the in-patient is being discharged he/she gives her/his medical documents to the receptionist who then takes the following steps:

Claim submission

The health facility submits the medication claim to the insurance company that is supposed to pay the medical bills of the patient. Submission is done by sending the documents of the patient by post or alternatively by scanning the papers. The documents that are submitted to the insurance company include a copy of the insurance card, charge sheets, and any other document concerning the patient (Walker, Larch, & Woodcock, 2004). Most hospitals prefer to submit claims by scanning them because it is faster and the documents can not tamper.

Verification of medical claims

Once the claims are submitted, the insurance company on the other end downloads the attached documents from the internet and cross-checks the papers provided to ensure the information is correct. If some relevant parts of information are missing, the hospital where the patient was treated is requested to insert the missing details and then submit it again. This communication takes approximately 24 hours after the claim is received but the process can be delayed if the claim is being submitted through the post because the hospital could be far from the insurance company premises.

Claim encoding

The claim is then assigned the necessary digits which are necessary because claims are arranged according to their categories and by encoding them it will be easy to retrieve them by their respective category rather than searching at random. The claims are stored in a computer-based database. This database is referred to when there is controversy because there are certain times when a patient can be withheld by the hospital when he/she does not produce the necessary records.

Claim Verification

The insurance company peruses the provided documents to ensure all the relevant details are correct and match with the records they have regarding the patient in question. A claim can be declined if the particulars in the claim are not clear, that is if the information in the claim is incorrect.

Additionally, some insurance companies are fond of declining claims which they feel do not fall under their docket. This is because there are limits to the services that are paid for by insurance company but this practice is not exercised by all insurance agencies. If the claim is declined the hospital is notified immediately and the hospital is requested to countercheck the claim and resubmits the claim (Burgos, Donya, & Keogh, 2006).

Claim Payment

After the claim has been verified, the insurance company proceeds with the payment which is done by writing a cheque that is then sent to the hospital. Alternatively, the insurance company may transfer money through bank wire directly into the hospital’s bank account.

Kutz (2009) argues that medical billing can be done by the hospital staff including the doctor or an outsourced company which is designated for that purpose but of late outsourced billing companies are doing a commendable job, unlike the doctors who make multiple mistakes because they are handling two tasks at the same time. Some practitioners are known to include services that have not been rendered to their patients in the charge sheets. This could be a mistake or a deliberate way of obtaining extra money from the insurance company.

A patient should do the following to ensure that he/she is being charged accordingly:

Demand for the latest statement from the billing party and check all the services listed in the charge sheets and their corresponding dates. Focus on major services such as scans and x-rays and write down all the services that he/she feels were wrongly entered on the charge sheet. Write a letter to the hospital or the billing company and make follow-up calls to find out if they have rectified the mistake.

If a patient receives a call from the collection representative informing the patient that he/she has medical expenses that have not been paid out, the collection agency should be asked to send documents that indicate the patient’s status and then call the insurance company and inform them about the matter. A patient should confirm that the services implied from the statement were rendered and if they are valid, he/she should consult his/her banking advisor because they might offer appropriate counsel towards settling the debt.

Conclusion

The above-mentioned scenario occurs when a patient has been seeking medical attention from different hospitals and also when the expenses are paid by different parties. This results in conflicts because when one insurance company pays a given amount, it may not be reflected in the records and the most obvious cause is human error. Whatever the cause of such claims, the patient should be cautious and should be aware of his/her rights because most patients don’t know their rights thus when they have extra charges they don’t bother to verify them (Burgos, et al., 2006).

References

Burgos, M., Donya, J., & Keogh, J. (2006) Medical Billing and Coding Demystified. New York, NY: McGraw-Hill Inc.

Kutz D.G. (2009).Medicare: Covert Testing Exposes Weaknesses In The Durable Medical Equipment. Darby, PA: Diane Publishing Company.

Walker L.D., Larch, S.M., Woodcock, E.W. (2004). The Physician Billing Process: Avoiding the Potholes in the Road to getting paid. Englewood, CO: Medical Group Management Association.

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