Medical Coding Overview
Claims Adjudication Occurs between a Healthcare Provider Submitting a Claim to a Health Insurance Company and the Insurance Company Making a Payment Back to the Provider.
Approximately 85% of Claims are Adjudicated by Computer Software without Any Human Review.
This Process is Called Auto-Adjudication.
If a Human Does Review the Claim, it Costs Approximately $20 Per Claim.
Most Health Insurance Companies also Set a Dollar Threshold of $10-$15,000 Per Claim Below Which Claims are Auto-Adjudicated.
Often the Software Used in Claims Adjudication is Very Old, such as the COBOL Software Language that was Created in 1959.
Claims Adjudication Software Does Not Catch All Doctor and Hospital Billing Fraud, Waste and Abuse.
For Example, ProPublica Reported at $10,000+ COVID Test That Was Paid by an Insurance Company and Quest Diagnostics Was Able to Lower its Employee Health Plan Costs by Catching Billing Errors that their Own Insurance Carrier Missed.
Please forgive the spelling errors on the whiteboard.
BACK To Healthcare Finance Video Library
BACK to AHealthcareZ Home
Approximately 85% of Claims are Adjudicated by Computer Software without Any Human Review.
This Process is Called Auto-Adjudication.
If a Human Does Review the Claim, it Costs Approximately $20 Per Claim.
Most Health Insurance Companies also Set a Dollar Threshold of $10-$15,000 Per Claim Below Which Claims are Auto-Adjudicated.
Often the Software Used in Claims Adjudication is Very Old, such as the COBOL Software Language that was Created in 1959.
Claims Adjudication Software Does Not Catch All Doctor and Hospital Billing Fraud, Waste and Abuse.
For Example, ProPublica Reported at $10,000+ COVID Test That Was Paid by an Insurance Company and Quest Diagnostics Was Able to Lower its Employee Health Plan Costs by Catching Billing Errors that their Own Insurance Carrier Missed.
Please forgive the spelling errors on the whiteboard.
BACK To Healthcare Finance Video Library
BACK to AHealthcareZ Home
Subscribe to Healthcare Finance Video Newsletter
The Current 3,000+ Subscribers Include: Employee Benefits Professionals, HR, CFOs, Insurance Brokers, Benefits Consultants, Doctors and Nurses in Leadership Roles, Hospital and Health System Administrators, Health Insurance Carrier and PBM Professionals, Pharma and Med Device Professionals, Academic Professors and Students in Healthcare Administration and Public Health. YOUR INFORMATION WILL NOT BE SHARED OR SOLD.