Insurance and medical institutions are key players determining the trust of the people to their services. For purposes of trust, creation and ensuring efficiency in the management of the new patients, the process of accessing an insurance claim should be simplified. There are different types of insurance covers and which differs regarding methods and even application of the claim. For one to conduct a medical insurance claim, a medical institution must have rendered services to an individual to allow the system to conduct Medical billing and make the necessary follow up216. The process of conducting an insurance claim involves the following steps;
The first step is planning, at this level, it is an obligation of the individual to find the company service providers and explain his or her plan for the institution to know and adjust based on the requirements of the client. The motive is to enable the customer to understand the routines, terms, and conditions of the company. Matters involving how co-pay works, co-insurance and other benefits that may arise from the cover should be at the disposal of the client. It is significant especially for the new patients to ensure retention and adequate information awareness. It is essential in reducing doubts and making the client aware of the charges and specific cover that will be provided by the insurance company.
Secondly, is the payment of a portion of the medical bill. Depending on the agreement of the plan, the insurer may agree to pay only a given portion of the medical bill while the rest is paid by the client. Also, there is a possibility that by the time a customer would be undertaking treatment, the cover would not be operational. In such a circumstance, despite the agreement, the client would be required to make payments referred to as deductible though it occurs on rare occasions. Notably, ability of an institution to offers services to the people varies from one
company to the next, and therefore, there are institutions that offer copay at this stage at a time when others are offering full coverage, therefore, it is dependent on the plan provided by the institution hence the need for full understanding of the scheme.
The third step is filling with the claim219. Logically, a claim cannot be filed unless the client receives services from the medical institution. At this step, the client is required to present the insurance ID card to the doctor for detail registration. After the presentation, the client might as well be required to give a copay, co-insurance or deductible depending on the initial agreement. In certain occasions, the doctor to provide the services may as well be on the same insurance plan network hence discounts may be issued. Immediately after the visit, the physician's notes involving consultation and services will be converted into certain codes which may be used to for purposes of understanding the claim. The Insurance Company primarily will use the code to understand the nature of the benefits which the client deserves.
The fourth stage involves forwarding, at this level, it is the responsibility of the health institution or the doctor on behalf of the institution to forward the codes to the insurance company. From the codes, the concerned insurance experts in conjunction with the plan will determine the exact amount which the client has benefited to determine the payment which they are to make. Notably, in a situation where the client has made copay, it implies that the insurance firm will only make payments for the deficit, an amount which is purely dependent on the plan.
The fifth step involves payment for the claim. After the act of forwarding the codes to the insurance company, it responds by sending a statement confirming the details of payment which is to be made by to the doctor. The basis is to distinguish the amount which is to be covered by the company and the deficit which the client is mandated to pay.
Finally is payment and explanation of benefits from the Insurance222. For purposes of ensuring transparency and avoidance of the questions, the Insurance Company usually sends the details of the payments to both doctors and client. The client is to be aware that the claim requested has been paid and to determine the amount which he or she owes the doctor. Furthermore, in a circumstance where the insurance fails to complete payment, billing occurs, and the clients take responsibility of the difference.
In conclusion, Insurance has the benefit of pooling risks and creating a pool of funds which can help an individual during difficulty. In the case of the new patients, it is for the insurance company to provide adequate information to enable them to understand the right procedures to obtain their claim effectively. The idea is to ensure that they are shown the correct protocol to follow. Importantly, the initial process involving the plan is quite important since it provides proper guidelines which are essential in the entire process.
Park, Y. T., Yoon, J. S., Speedie, S. M., Yoon, H., & Lee, J. (2012). Health insurance claim review using information tecshnologies. Healthcare informatics research, 18(3), 215-224.
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