Medical Claims Processing Software

Submitting a healthcare claim requires medical claims processing software. It is often difficult to work with large insurance companies to receive proper payment for services rendered to patients and clients. Not only is there a lot of bureaucracy involved, governmental regulations, differences in billing procedures and statutes of limitations all complicate the process. A reliable, knowledgeable employee, using a sound medical insurance billing software program is a physician's, hospital's, or clinic's first line of defense in successfully garnering payment for healthcare services performed. The software available is systematic in the way claims are entered into the computer. Medical claims processing software also keeps meticulous records in a database and prints out a paper copy for filing. Luckily, the protocol for submitting invoices is the same whether or not the insurance company is privately owned or governmentally run.

The process of filing is the paper "interaction" between an insurance company and the original healthcare provider. The initial visit begins this interaction. Usually, a physician will request a new patient's insurance information or an existing patient's information if he has changes healthcare coverages, companies or plans. This information is kept in the patient's file. Healthcare files contain all the patient's history of treatment and diagnosis. Eventually, this will become crucial in determining if the individual had a preexisting illness that led to the office visit, or if this was the initial occurrence of the injury or sickness. Information of this nature is needed, as many healthcare claim representatives allot a different amount of coverage and allowable expenses for preexisting conditions versus initial occurrences. Using the patient's testimony of the present symptoms, personal health history and clinical testing if needed, the physician will then determine the correct level of care and service to provide.

Determining the correct level of service and care to provide to the patient is also vital, because the bill will only be paid if the physician decides correctly on the allowable care. If a diagnosis is unable to be determined, the symptoms will be recorded for payment purposes. Once the correct level of service is determined, the physician then administers the necessary medicine or treatment. The level of service is translated into Current Procedural Terminology. The CPT is always five digits long. The healthcare professional's verbal diagnosis of the patient is also translated into a numerical code. The numerical code for the verbal diagnosis is determined through consulting a database called, ICD-9-CM. Both the CPT and the ICD-9-CM are vital in submitting a bill for payment.

After translating the diagnosis and treatment into numeric codes, the medical insurance billing software will then transmit a bill electronically either directly to the insurance company (payer) or to a clearinghouse that processes invoices for numerous healthy indemnity companies. For years, the bills were sent on a paper form called CMS-1500. Many small medical offices still transmit bill information on CMS-1500 forms. In the event that a medical practice is still sending paper invoices, medical claims processing software still produces the paper bills.

The payer then employs healthcare specialist to review the electronic bill or the CMS-1500 form produced by the medical insurance billing software. The specialist reviews the invoice, considering the patient's history, patient's eligibility, provider's credentials and medical necessity. After review, the payer either accepts or rejects the claim. If the bill is accepted, the payer agrees to pay a predetermined percentage of the services rendered by the healthcare professional. If the bill is rejected, it is then sent back to the healthcare professional with an explanation of why it was denied. The healthcare provider will then look at the rejection notice, reconcile it with the original bill, make requested changes and resubmit it to the payer. The invoice then goes through the review process again. This cycle of denial and revision can continue until the payer agrees to pay the agreed upon percentage of the original bill, or the healthcare professional gives up and accepts only partial payment by the health indemnity company. Rejections, denials and overpayments can be quite common. Sometimes up to 50% of invoices are rejected. The complexity of claim format is usually blamed for high failure rate. Again, the advances being made in medical insurance billing software is taking the guess work out of medical bills and enabling healthcare providers to submit correctly the first time.

Health Insurance Portability and Accountability Act (HIPAA) protects the information in patient's files. HIPAA urges healthcare professionals to file claims electronically in compliance with their regulations. The regulatory body of the Health Insurance Portability and Accountability Act houses a database that can be referenced even before services are performed. In this way, a physician can check a patient's eligibility before prescribing medication or initiating treatment. They were now required to submit all large financial activities electronically to a centralized HIPAA approved system. As a result of some of the newer HIPAA regulations, healthcare professionals had to upgrade their medical claims processing software. Though this was a small price to pay for increased efficiency, patient protection and fewer rejected invoices. Receiving payment for services rendered, invoicing correctly and determining patient eligibility is by no means simple, but with the advancements in medical insurance billing software, it is getting easier and easier to go to the doctor, file a bill and focus on recovering. "When Jesus heard it, he saith unto them, They that are whole have no need of the physician, but they that are sick: I came not to call the righteous, but sinners to repentance." (Mark 2:17)

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