Medical Billing 201

Welcome to the second article discussing some of the intricacies of medical insurance billing and how it impact's you as a patient.

If you have not already, please consider reviewing our Medical Billing 101 post.

 

Overview

We are going to be covering several aspects of insurance billing in this article.  The typical billing process and procedures were covered in our previous article, and we will focus more on some common issues/concerns that hit patients.

We will break things down in 3 major sections:

Licenses, Networks and Credentialing (Oh My!)

These are all issues that could have a major impact on whether your benefits get paid.  In most cases you don't need to know all these details if you are willing to confirm coverage via a phone call to your insurance company, but it is good to understand how any of these criteria could result in denials of your insurance claims.

“Medical Necessity”

This is another area where your benefits could be impacted by determination made by your insurance company.  Medical necessity is determined by your insurance company, and the determination of medical necessity may not be solely determined on what is best for your health and wellness.

Labs

Lab billing is interesting as it is a combination of your physician's order (including diagnosis codes), as well as the labs network status with your insurance company.  Lab billing (including patient invoicing) is generally handled entirely by the lab and not your physician or physicians office.

Licenses, Networks and Credentialing (Oh My!)

Licensing

Your medical providers are licensed by the state in which they practice medicine.  Based on their license designation, they are assigned a scope of practice within their state.

In Washington State, you can lookup your providers licensing status using the Provider Credential Search tool.  This tool not only tells you the credentials of your provider, but can even let you know if your physician or medical assistant has had their license expired, terminated or suspended.