INTRODUCTION

Being the new reimbursement manager, I hope to work with you all for the benefit of this entity.

I manage reimbursement transactions, as well as facilitating training to executive staff on new policies.

I take part in the preparation of departmental budget.

I also negotiate for contracts with outside vendors. Generally, I am responsible for keeping track of all

files, in this case reimbursement files in relation to insurance.

ROLES AND RESPONSIBILITIES OF REIMBURSEMENT MANAGER

Developing strategies to facilitate consumer support in relation to issues of reimbursement.

Management of transactions. Training and coaching executive staff on new policies

(Marylyn, 2007). Analyzing and interpreting financial data, as well as cost

reports. Building relationships with staff and insurance providers. Use software programs to keep track of data records. Medical coding. Get payments made on overdue accounts. Establish connections with the insurance companies and the

representatives.

TYPES OF CLAIMS

PAPER CLAIM Submitted manually and delivered to insurance companies. Take around 60 to 90 days for processing. More expensive considering the time and processes required. High chances of inaccuracies.

ELECTRONIC CLAIM Billing claims for services are done through electronic means. Care provider uses a software to ascertain the eligibility of the

patient for the needed services. Uses the same technological standards as the electronic claims

transmission. The response if received by the payer t through a direct electronic

connection. This is referred to as the health care eligibility and benefit response.

PAPER CLAIMS ELECTRONIC CLAIMS

Turn over time is 40/60/ Rejections are valued

at 35% depending on clerical errors.

Cost of paper claim us $7.

The time on each claim is approximately 10 minutes.

The average rejection rate due to electronic errors is 2%

They are prioritized over paper claims.

Paid between seem to twenty one days.

Follow up procedures are drastically reduced.

Reduced cases of adjudication errors.

PROCESS USED AT THE FACILITY

Assignment. The auto claim is assigned to professional, endowed with the responsibility of guiding you through the entire process with the help of a team of claim specialists,

Initial contact. Claims professional communicated with you concerning the auto claim. This enables him to:

Obtain initial information about the loss. Explain how the claim will be managed. Suggest ways to prevent damage in future. Schedule an in person appointment.

Evaluation. Claims professional conducts inspections to determine presence and extent of loss. Facts are gathered. Documentation is made. Witness is interviewed. Photos are taken. Formal evaluation of claims are made.

Resolution. Claims professional issues payment based on estimates. Claim closure. This is done in accordance with the terms of policy.

IMPORTANCE OF EDIT

Electronic data interchange is the technological process of moving data within organizations in structures formats.

This technicality allows transfer of information from one location to another.

It is important since it facilitates the change of information between various parties in a business transaction (FOURDNEY, 2013).

Allows paperless transfers of unimportant data. Enables electronic commerce. Automates business processes.

LIFE CYCLE OF AN INSURANCE

This is the process a health insurance claim goes through since its submission to its payment.

Submission. - Transmission of the claim to the insurance provider electronically in the case of our organization.

Processing. - The payer collects information about the patient, the medical service provider and concerning the services to be delivered.

Adjudication. -Editing of provided information is facilitated. -Verifications are made concerning health benefits and payer rules. - The services which have been billed are confirmed.

Payment/denial.-Claims can either be denied or accepted by the payer. -The payer may generate a remittance or explanation of provided benefits at this stage.-An explanation is given on how the claim was processed.-A cheque is mailed together with the specific explanations.-Payment is received by the medical service provider.-It is posted into the patient’s account.-Remaining balances are billed out to the patients.

COMMON REASONS FOR CLAIM REJECTIONS

Took too long to file the claim. Beyond 60 to 90 days is a late presentation of claims and this my be a reason for their rejection.

Lack of proper codes. The diagnostic codes and the procedure codes may be

incomplete, invalid or missing. Preauthorization or authorization. Lack of preauthorization is a direct rejection of the claim. Expiry of claim (Marc, 2002). If the claim is not posted before the deadline, this is a late claim

and may be rejected. Lack of referral from a physician. This in most cases leads to a delay. Provision of more than required number of services in one day.

SUMMARY

Health insurance is important in various ways. Preventive services can be accessed. Financial distress is eliminated. Soon treatment is obtained. Insurance claims are helpful since compensations are

a source of burden reduction to the individual. The use of electronic claims should be encouraged. This is because of accuracy and efficiency as

compared to paper claims. Insurance providers should not be discriminative in

the case of service delivery.

References

Marylyn, F. (2007). Administrative Medical Assisting. London: Cengage learning

Fourdney, M. (2013). Insurance Handbook for the Medical Office. London: Routledge publishers

Marc, S. (2002). Manual Reimbursement for Meical Genetic Services. New York: John Wiley and sons