How Health Care Pricing Programs Are Distinct From Those In Other Sectors

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Medical billing is the process whereby a health care provider follows up on claims with companies of health insurance. The goal of the process is for the healthcare provider to receive reimbursement for the services he has rendered to a patient. The following therefore is a description of the medical billing process used by a healthcare care provider in the production of the final bill. The final bill is to be sent to a healthcare insurance company so that the health care provider can obtain full reimbursement for the services he has rendered to a patient.
The first step involves a patient visiting a hospital facility. A healthcare provider attends to the patient, and the patient is required to provide vital information that will aid the health care provider in determining which services the insurance plan of the patient cover. The patient’s coverage is determined so that the bill can be assigned correctly to the health insurance company and also determine if the insurance plan of the patient has covered the service being provided. If the insurance plan of the patient covers the service being rendered, the healthcare provider prepares a medical report. The medical report contains the information of the health care provider, the name of the patient, a description of the procedures used and the medical diagnosis. The medical report prepared is then transformed into universal numbers of medical codes by a medical coder. The codes aid the health care insurance company in some ways, for example, helps it to determine the medical necessity of the services rendered and the coverage (Rimmer, 2008). After the medical report has been transformed to universal numbers of codes, the healthcare provider puts it into a claim form. The health care provider also includes the cost of the service rendered in the claim, and he does not include the total cost but rather the cost he expects the health insurance company to pay as presented in the payer's contract with the healthcare provider and the patient. The healthcare provider electronically transmits the claim to the healthcare insurance company for reimbursement. The claim sent to the health insurance company should meet the standards of billing compliance so that cases of it being rejected can be eliminated. The claim, therefore, is the final bill the healthcare provider produces for which full amount can be paid and if the medical directors of the health insurance company review the claim and state that it is not valid, it rejects it and sends it back to the healthcare provider for corrections to be made. Once the necessary corrections have been made the health care provider resubmits it so that he can finally be reimbur...