The Health Care Claim Life Cycle 101

The Health Care Claim Life Cycle 101

Faculty

Christine Burke Worthen, Epstein Becker & Green, PC

Every time an individual receives a health care service (e.g., annual check-up, physical therapy, blood test, outpatient surgery, CT scan, emergency care, etc.), the health care provider submits a “claim” to the patient’s health insurance plan. Obtaining reimbursement for health care is a complicated financial process that involves several moving parts, such as reconciling insurance payments, making contractual adjustments, writing off losses and unreceived payments, and determining the amount owed by the patient. This course explains the many laws and regulations that spell out the rights, responsibilities, and obligations of all parties involved in shepherding a claim from Point A to Point Z.

Course Syllabus

1.      The Humble Health Care Claim Has an Entire Life Cycle of Its Own

2.      Laws and Other Governing Rules That Regulate the Health Insurance Industry

3.      How Does the Provider Get Paid?

4.      The Health Care Claim and Its Life Cycle

5.      The Pre-Claim Submission Process

6.      A Brief Detour into the World of Medical Coding

7.      The Pre-Claim Payment Process

8.      Payment Determination

9.      The Post-Payment Process