The convoluted world of medical insurance payment
The good old days
In the good old days the country Dr. carried a black bag and visited the patients at home in addition to seeing them in his clinic. The doctor would charge whatever he felt was appropriate for the service he provided to the patient and sometimes used to modify it according to the paying capacity of the patient and the amount of work he has put in. Sometimes it was common for the doctor to be paid in kind rather than in cash.
As medicine progress and healthcare became a business many companies in USA started providing "health insurance" basically they were paying for the medical treatment of their workers so that the workers can keep their health and continue to work with efficiency. This was the main premises behind employer paid health care benefit. Later on they started asking the workers to bear a percentage of this cost in order to decrease their input costs. In later days they relegated this whole process to a company which would provide insurance based on the number of workers signed up by the company this insurance company is called the third-party payer.
As the number of medical procedures became more complex and more expensive the insurance company started to find various methods to reduce their costs.
One of the main methodologies is claim denial
asking for preauthorization
software usage for automatic edits and denials
clinical guidelines
utilization reviews
denial of participation in the network for certain providers who would not toe the party line/
Let's for example take a look at what is called claims processing lifecycle
So as physicians not only do we have to learn the life cycle of parasites but also the lifecycle of claim for payment to the insurance company
which is basically a different kind of parasite
The good old days
In the good old days the country Dr. carried a black bag and visited the patients at home in addition to seeing them in his clinic. The doctor would charge whatever he felt was appropriate for the service he provided to the patient and sometimes used to modify it according to the paying capacity of the patient and the amount of work he has put in. Sometimes it was common for the doctor to be paid in kind rather than in cash.
As medicine progress and healthcare became a business many companies in USA started providing "health insurance" basically they were paying for the medical treatment of their workers so that the workers can keep their health and continue to work with efficiency. This was the main premises behind employer paid health care benefit. Later on they started asking the workers to bear a percentage of this cost in order to decrease their input costs. In later days they relegated this whole process to a company which would provide insurance based on the number of workers signed up by the company this insurance company is called the third-party payer.
As the number of medical procedures became more complex and more expensive the insurance company started to find various methods to reduce their costs.
One of the main methodologies is claim denial
asking for preauthorization
software usage for automatic edits and denials
clinical guidelines
utilization reviews
denial of participation in the network for certain providers who would not toe the party line/
Let's for example take a look at what is called claims processing lifecycle
So as physicians not only do we have to learn the life cycle of parasites but also the lifecycle of claim for payment to the insurance company
which is basically a different kind of parasite
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