Reimbursement concepts. Business & Marketing Essay

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3-1 Discussion: Claims Processing and Reimbursement
In healthcare there are many different types of payers including: 
• Federal (Medicare, Tricare, Children’s Health Insurance Program)
• State Funded (Medicaid, Children’s Health Insurance Program)
• Private Insurance (Blue Cross Blue Shield, Harvard Pilgrim) 
• Commercial Insurance (Humana, Cigna, United Health)
Claims processing are all the same in which when the insurance company is billed, and they pay their portion then the remaining balance is then billed to the patient. Another comparison to the different type of billers are each claim needs to be done in a timely manner and be error free so that there is no delay in reimbursement to the supplier.
At a job that I previously worked there were a lot of documentation that would not get completed in a timely manner. I had a specific physician assistant I was a secretary for and when we worked closely with the provider, I would have to send multiple messages to the provider to make sure she finished her note from seeing that patient. There were multiple things that would happen because her documentation was not completed and signed. One being claims could not be processed for that visit. Another reason that it is important to get all the documentation complete in a timely manner is so other testing or appointments can be made. For example, I worked for a Gastroenterologist and if they need to refer the patient to get a esophageal manometry test ( which is to test to measure the function of the esophageal sphincter) they would need the last office visit in order to book the patient and if they did not receive further testing for the patient would be delayed. 
There two different types of claims. The first is an institutional claim which is any claim that is submitted using HIPPA mandated transaction or the UB-04 paper claim form. The second claim is a professional claim using HIPPA mandated transaction or the CMS 1500 paper claim form. The CMS 1500 form and the UB-04 claim have some of the same sections which include patient information, insurance information, dates of services rendered, and provider’s NPI number. The CMS 1500 and UB-04 differ because of diagnosis codes and specific provider information.
Ethics are a key part of the coding and billing. If a coder is not being honest on claim forms and are overbilling individuals to get a higher reimbursement this is something that is illegal and fraudulent and could end up getting jail time.  If you see a coder not being honest then it should be brought to a supervisor immediately because not saying something is unethical as well. Coders have access to everything from codes to services to patient’s demographic information including their social security number. They need to follow the HIPPA guidelines because violating these can end up in fines and jail time.
Reference: Harrington, M. K. (2021). Health care finance: and the mechanics of insurance and reimbursement (2nd ed.). Burlington, MA: Jones & Bartlett Learning.