Insurance Claims Processing and Adjudication Unit 5 Discussion
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Medicine
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Apr 3, 2024
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The Life Cycle of an Insurance Claims begins when a patient schedules an appointment with a physician and services are rendered. The services provided translate into charges that can be billed to the insurance provider and the patient. The cycle is complete after all payments and adjustments have been completed for services rendered.
Review Unit 5 and include the following in your initial post:
Considering your chosen position (medical assistant, medical office administrator, medical coder, or medical billing and insurance specialist)
1.
What area(s) of the life cycle of the claim is affected by your position? Explain how you will ensure that you are providing error-free information. As a medical billing and insurance specialist, how the physician fills out the superbill (or encounter) form will affect how smooth the job will be. If the physician does it correctly and makes sure all the information necessary is included it will make the job run smoothly. However, if it is done incorrectly or missing information it will have to be sent back to the physician to be fixed, which will increase the amount of time for the claim to be completed and increase the possibility of an error occurring. A medical billing and insurance specialist would also prepare and transmit the claim, this needs to be done meticulously because the smallest error can result in a denial and no payment on the
claim. Once the claim is received by the insurance company it goes through the adjudication process and the medical billing and insurance specialist waits for the outcome of the process, whether the claim is accepted, denied, or rejected. The outcome of the claim determines the next step that is taken. If it is accepted it has been paid and can be sent to the secondary insurance or the EOB can be sent to the patient for any needed payment. If the claim was denied, the error can be fixed on the claim and resubmitted for processing. The best way to ensure that the information that is submitted is free of errors is to become familiar with each type of claim form and what information goes in each box of the claim. Also entering the information carefully and double-checking that it is correct before submitting it is key to ensuring
it is error-free.
2.
What area(s) of the life cycle of the claim do you find challenging? Explain how you can learn more about these areas? The only aspect of the life cycle of a claim that I do not have experience with is the superbill (or encounter) form. It seems easy enough to grasp. I was able to
learn more about these different areas by working with claim adjudication at an insurance company and by data entering claims.
3.
Patient Collections and the Law are vital pieces to the life cycle of a claim. Explain what is allowed and not allowed according to the Fair Debt Collection Practices Act (FDCPA). The Fair Debt Collection Practices Act (FDCPA) places limits on how debt collectors can contact debtors about a debt. Debt collectors are not permitted to contact debtors publicly via social media. If the debt collector is contacting someone electronically (text message, email, etc.) they are required to offer a simple way to opt out. They are also generally prohibited from making any calls before 8 a.m. or after 9 p.m. The FDCPA also hinders debt collectors from using malicious, unfair, or deceitful practices to collect debt (Consumer Financial Protection Bureau, 2023). The FDCPA requires that debt collectors identify themselves in every communication and provide the
name and address of the initial creditor. The debt collector needs to notify them of their right to dispute the debt (Ballotpedia, n.d.).
References:
Ballotpedia. (n.d.). Fair Debt Collection Practices Act. https://ballotpedia.org/Fair_Debt_Collection_Practices_Act
Consumer Financial Protection Bureau. (2023, April 14). What laws limit what debt collectors say or do? https://www.consumerfinance.gov/ask-cfpb/what-laws-limit-what-debt-collectors-can-say-or-do-en-
329/#:~:text=The%20FDCPA%20prohibits%20debt%20collection,%2C%20family%2C%20or
%20household%20purposes
.
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