If you have ever been in hospital, even as an outpatient, you will probably be aware of the process of medical billing. In countries where there is a National Health System—such as Canada and the United Kingdom—there is no insurance company involved with the treatment of a hospital patient. The hospital purchases its supplies and the patient doesn’t pay a cent for a doctor’s visit, a trip to the ER or a stay in hospital. However, in the United States, insurance is big business. Without the luxury of a national health service the entire country relies upon the insurance companies to accept or deny applications for treatment. Many see this as unfair because they pay their premiums and they deserve the treatment they pay for. When people are taken to hospital or treated in a hospital every tiny little item from a band aid to a headache pill is billed individually. Each item used by or on the patient is logged in an invoice which is then sent to the billing department within the hospital. The billing department then begins the billing cycle, whereby they create an invoice to send to the insurance company.
The Process of Payment
Let’s take a typical community hospital in Orlando as an example. As a hospital, they will run in pretty much the same way as a business, with an administrator and a finance department which determine the finances and budgets of the hospital. Many hospitals in the United States often rely on private donations by wealthy people to finance research or a wing of the hospital, otherwise they may not be able to stay afloat. They may also use medical bill auditing services to keep their records straight.
Once a doctor makes their diagnosis they will make note of certain procedure codes, which are effectively, used for the purpose of the insurance company to decipher whether a treatment is essential. The complete process of medical billing department will then send the claim to the insurer. Oftentimes a medical insurance claims adjuster will become involved to ascertain the necessity of certain treatments, drugs or supplies. A claim can be denied or rejected, but there is a stark difference between the two. A denial is a bill that an insurer plainly refuses to cover or pay for on the client’s behalf. A rejection is a claim that the insurer simply refuses to process without the chance of appeal.
