Healthcare.gov gives us a pretty good, succinct answer to the question of “What is a medical claim?” As they write, it’s a “request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.”
It may be worth delving a little deeper into the topic. Even though that’s a decent definition of a medical claim up there in that first paragraph, there are a few wrinkles to it which you don’t really see until you open it up and spread it out on the table.
Before we get started, please remember that, if your medical practice needs any of our medical billing services, we’re always happy to partner with new clients. Give us a call today, and we’ll go over our full suite of options:
- Medical Billing
- Anesthesia Billing
- Neurosurgery Billing
- Medical Practice Management
- Revenue Cycle Management
- Medical IT
- Medical SEO
- Medical Billing Consulting
- Request for Payment
Making A Claim
As the definition of medical claims above suggests, a claim is a request for payment for services “you think are covered.” If you dig a little deeper into HealthCare.gov’s glossary of terms, you’ll find that “health coverage” is defined as follows:
“Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).”
Dummies.com has an excellent piece on the medical billing claims process. They write, “Claims processing in Medical Billing and Coding refers to the overall work of submitting and following up on claims. When you’re not interfacing with the three Ps — patients, providers, and payers — you’ll be doing the ‘meat and potatoes’ work of your day: coding claims to convert physician- or specialist-performed services into revenue.”
More than 150 clients rely on MBA Medical for medical billing. Our services are part of the overall medical claims process and the insurance claims process. And one major aspect of the work we do is to identify payment patterns. As we wrote in a 2017 blog post, “How To Track Claims And Denials”:
“Insurance companies process codes and claims in a number of different ways. If you identify patterns in their payment, you can dramatically reduce the number of denials and make the overall tracking process much simpler. … You can assure that the appropriate diagnosis code is included on claims for that service to reduce denials, appeals, and turnaround time.”
In other words, medical claims are part of a complex system of healthcare and revenue cycle oversight that includes healthcare providers, patients, insurers, and billing companies, such as MBA Medical.
Many of us are familiar with the billing process from a patient’s perspective. It involves types of insurance coverage and insurance plans, managed care, claim forms, EOBs (explanation of benefits), PPOs (preferred provider organizations), point of service (POS plans), pocket expenses, and more.
It can be tough to make sense of it all — not just for patients but for providers as well.
Tracking Medical Claims
Tracking claims is one way to ensure that medical providers can generate revenue. Another method involves the appeals process. As HealthCare.gov explains, an appeal is a “request for your health insurance company or the Health Insurance Marketplace to review a decision that denies a benefit or payment. … If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.”
The majority of denied claims are eventually paid through the appeals process. MBA Medical does the footwork for health care providers. Many providers give up when a claim is denied. They simply don’t have enough time, understanding, experience, or manpower to follow up.
MBA Medical does, though. It’s just one of the reasons we’ve been the industry leader in medical billing services for more than two decades.
Give us a call today or request a consultation to see how a partnership with MBA can benefit your practice and your patients.