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The Healthcare Finance Industry has become one of the most talked about subjects over recent years. Extreme medical costs, Mal-practice liabilities, Insurance premiums, and Government-Medicare and Medicaid have become very ‘hot topics'.

At the time of illness we are in search of medical care. Once we have entered a Healthcare facility the financial process begins. We meet a Healthcare provider, and a Medical record of this visit is compiled. This claim includes demographic information, such as name, address, phone number, place of employment, insurance information, and Medical testing/treatment information.  Once this is completed, begins diagnosis, treatment and ultimate discharge. The Service Provider must receive reimbursement for the services provided so a Medical Claim is generated.  This claim is then submitted to the insurance carrier for reimbursement.
Once the carrier receives this claim form, which could be a HCFA-1500 (outpatient) or a UB-92 (in-patient), it is scanned, adjudicated and if the insurance carrier deems this claim and the services provided were ‘Medically Necessary' it will be processed for payment. Depending on the contractual agreement between the Healthcare provider and the Insurance carrier the claim is paid at a pre-determined rate.

Now, during this era of Managed Care, claims are heavily scrutinized.  Over the past few years, medical claims have been denied for reasons such as, an incorrect social security number, an inaccurate diagnosis or a procedure code. Today even Healthcare providers need to send certain information from the Medical record itself to prove “Medical Necessity”. By the time the Healthcare provider realizes that this information needs to be corrected or provided, the turnaround time has left them with an additional issue, TIMELY FILING. You have a certain amount of time to get an accurate claim to the insurance carrier. Depending on the insurance carrier or government entity this could be from 30 days to 1 year.