Just for the sake of argument, let us take a typical day in the life of a medical billing company in Orlando FL. They start the day by looking through the list of requests put through during the night. Those lists are more likely to contain visits to the emergency room for emergency treatment and usually the insurance company will either accept a request, deny a request or reject a request. Rejecting and denying may sound similar, but in reality they are completely different. In layman’s terms a denial is claim which is generally turned down but can be appealed and re-priced. A rejection is a flat out ‘no’ from the insurance company. There is no option of appeal and the claim is a dead claim. An acceptance is exactly that, the insurance company will pay every and all costs in connection with the treatment.
The initially process starts with when the doctor sees the patient, examines and diagnoses the patient. They are then required to list everything which is then sent to the insurance company for their decision. Oftentimes an insurance adjuster will be a sort of middle-man who steps in on behalf of the insurance company to determine that all stated costs have been fairly marked down and not over charged. The initial transaction is a medical billing services in Orlando FL claim referred to as ANSI-837 or X12-837 and it is an acknowledgment of a claim submission.
Electronic Billing Processes
The insurance company will respond to a claim with a X12-997 and the claim goes forward into further processing. Adjudicated payments are usually responded to with a X12-835. The billing can be a very confusing and complex process owning to the amount of insurance policies a company might have. Many insurance providers have up to ten or fifteen different plans and contracts with various providers. Once the bill is submitted the adjuster determines the fairness and then the claim is either denied, rejected or accepted. If the claim is rejected the treatment can either proceed pro-bono or the patient will be billed separately by the hospital billing service once they have completed their initial treatment. The insurance company is then out of the equation altogether. If the claim is denied it can be appealed, usually by an insistent doctor.
