De-Mystifying the Medical Billing Maze

                                                                                         

Medical billing can follow a very complex and strange process. For those who don’t or haven’t actually worked as doctors, or for insurance companies, the procedures can be quite opaque, but fundamentally it is quite simple.

When a patient goes to a medical provider for surgery or to be put on medication, or simply to diagnose conditions the patient has been experiencing, there are certain costs for each service the medical practitioner provides to the patient. The provider records these costs in a form, usually a HCFA, or “hic-fuh,” which can be either electronic or paper. The HCFA is then sent to the patient’s insurance company, or sometimes to a clearinghouse or other middleman that can process the claim. When processing a claim, the insurance company looks at how valid the charges that the provider put on the claim are. Different companies have different systems for determining this, but in general it can be expected that about half the charges the provider put on the claim will be paid by the insurer, and half by the patient. Things like a deductible, co-pay, and coinsurance can have a heavy bearing on how much the insurer is willing to pay. If the patient has coinsurance, for instance, the insurance company is obligated to pay for a certain percentage of all the charges on the medical bill.

When the insurer has decided which charges are valid it returns the claim to the medical provider, in either electronic or paper format depending on their customs. Once received the medical provider looks at and analyzes the claim to see what the insurer has agreed to pay. If none of the charges were rejected by the insurer the provider then they will soon pay all the charges on the bill. If any charges were rejected, the provider must make changes to the bill and then return it to the insurer. If, once returned, the information on the bill is accurate the insurance company will pay it. But as with before, it might reject some of the charges, and if so the bill will be returned to the provider, and so on until the provider submits a medical claim the insurer can agree to pay the charges for.

Once the insurance company has agreed to pay for all the charges the provider has listed it falls on the provider to go to the patient to collect any unpaid charges.

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