The Medical Claims Process Explained Simply

Posted: Dec 17, 2019

The Medical Claims Process Explained Simply

It’s stressful enough to have medical problems. Having to worry about paying for treatment and the medical claims process is an added complication and pressure.
The insurance and medical symptoms are famously complicated. It’s not easy to understand what goes on behind closed doors, so here, we hope to explain the medical claims process simply.

The medical claims process follows these steps:

  • You receive treatment or attend an appointment,
  • The doctor sends a medical bill to your insurance,
  • A medical coder processes your claim,
  • The insurance company reviews your claim,
  • You receive the amount that you owe.

Let’s dive into each of these.

You See Your Doctor

Treatment can be anything from heart surgery to a wellness check-up. Treatment can also include therapeutic services, like physical or speech therapy.When you see your doctor, your doctor’s office staff will ask you for your insurance information. That way, they know where to send your bill.

For many services, such as the services provided by a specialist or general practitioner, you will pay a copay. Copays are a fixed amount for certain services. You can find details about copays (which vary depending on the service) in your insurance plan.

Your Doctor Sends a Bill

After your visit, operation, or treatment, your doctor writes up the exact services they provided. Doctors account for everything. For example, if you had a lengthy hospital stay, each night is accounted for. Or, if you needed additional blood work during your physical, your doctor will include that in his or her bill as well.

A Medical Coder Codes Your Bill

Upon receiving your doctor’s bill, a medical coder analyzes the doctor’s bill and assigns different codes to each service. These codes allow your insurance company to account for what and how much is covered by your insurance plan.

The Insurance Company Reviews Your Claim

After receiving the coded bills, your insurance company determines what is covered, how much they owe, and how much you owe. These numbers vary entirely based on your health care plan.

In most health care plans, you must pay a certain amount before the insurance company helps you cover your medical bills. This is called a deductible.

When reviewing your medical claim, the insurance company takes into account many things, including the following:

  • If you’ve paid your deductible,
  • If the treatment was provided in-network, and
  • If the treatment you received is covered by your plan.

After your insurance company determines what you owe, they report back to your provider, informing them what they are paying for and what you still owe.

You Receive the Final Bill

Eventually, you will receive a bill from your provider detailing what you need to pay. Sometimes, errors occur during the medical claims process, so it’s important to carefully read your bills and know your health plan in detail. Bills can be paid online, in-person, or over the phone. Typically, your bill will include instructions on how to pay your provider.

Do You Have Questions About the Medical Claims Process?

This simple explanation of the medical claims process doesn’t cover all scenarios. In some cases, there is a lot of back-and-forth between your provider, your insurance company, and you. As we mentioned above, a lot can go wrong, but you’re not alone in facing the medical claims process.

If you have questions about the medical claims process, ask your doctor. Your provider is on your side and will help you navigate the medical claims process if need be. For other questions about the medical claims process, please contact Button Family Law today. We prioritize patient-centered care, and we’re here to help you with your medical questions and claims.