Friday, March 28, 2008

Fitness, Health, Medical Service Providers and Medical Billing Services

A fit person may be a healthy person, but a sick person cannot be a fit person. Health is important to maintain fitness, but however fit you may be, a very fit person may still fall sick. Getting back to a healthty state is important to get back on the path to be fit.

Getting healthy again means getting medical treatment from medical service providers. Usually, the bills will be picked up by insurance companies or Medicare if the person seeking medical treatment is in Australia, Canada or the United States of America. I

From what I know of the United States of America, it is very common to have medical billing companies act as intermediaries between the medical service providers and the insurance which, if everything is in order, will pick up the tab for the sick patient who received the medical treatment.

Note the phrase "if everything is in order." Getting what is due to you from insurance companies or medicare is not just a matter of sending off an invoice off to them and getting paid in full the next day or a bit later. The process if it is done by the medical professionals, will reduce them to clerks rather than medical professionals.

According to Wikipedia, medical billing involves accessing and creating the patient medical records, submitting the diagnosis if any or if there is no diagnosis, the reason for the visit will be cited for the purpose of claims filing. The extent of the physical examination, the complexity of the medical decision making, and amount of background information (history) obtained from the patient are evaluated to determine the correct level of service that will be used to bill the insurance. The level of service is translated into a five digit procedure code from the Current Procedural Terminology. The verbal diagnosis is translated into a numerical code drawn from the International Classification of Diseases, Ninth Edition, or ICD-9.

The procedure and diagnosis codes together with the claim will be transmitted to the insurance company or medicare electronically after formatting the claim as an ANSI 837 file and using Electronic Data Interchange. This is transmitted directly to the insurance company or to medicare or via a clearinghouse.

The insurance company's medical directors will review the claims and evaluate their validity for payment. It may be rejected or subjected to negotiations plus the payment offered may be reduced. This process may go through more than 1 cycle. Which medical professional would want to subject himself or herself to such processes? They would become clerks rather than doctors.

Further, such claims often mey be aided by medical practice management system software which a medical billing service which specializes in medical claims may be able to afford, but not a small medical practice.

Further, according to Prefered Health Resources, a medical billing company, claims adjustment rate of between 20% and 35% is considered good and acceptable. Prefered Health Resources claims to be able to achieve adjustment rate which is consistently lower, in fact as low as 12% in the case of Medicare.

If true, not only they take all the tedious work of filing a claim off the hands of medical practioners, they can actually help them to get better returns for their services rendered.