Description
In your opinion, which payment method is most preferred by physicians in the Kingdom? Explain your rationale.
-Dr. Robert
this is my dis was
Trigger Situation
Typically, a covered person’s request for healthcare services covered by their insurance policy and subject to reimbursement results in a medical insurance claim (Worth & Mytinger, 1996). Consider a hypothetical situation where an individual, Ms. Johnson, requires medical attention, initiating a medical insurance claim.
In this case, Ms. Johnson is a policyholder. She complains of acute chest pain and is taken immediately to the hospital’s emergency room. According to the attending physician, she has acute appendicitis. This requires an immediate appendectomy. This condition qualifies for a medical insurance claim because Ms. Johnson’s health insurance plan covers hospitalization and surgical treatments.
Resolution Path
Her doctor starts the claims procedure when Ms. Johnson’s health has returned to normal. This entails acquiring all pertinent billing information, medical records, and supporting evidence. The healthcare provider starts the claims processing process by submitting these documents to the insurance provider.
Time Limits and Importance
Time constraints are essential to the resolution of this claim. Most insurance policies have strict time limits for filing claims following the delivery of medical care. Ms. Johnson is responsible for ensuring that her healthcare provider submits the claim within the allotted time window, normally 90 days after the service date. If one attends this date, their claim may be accepted, or the procedure may take longer (Worth & Mytinger, 1996).
After receiving the claim, the insurance provider examines the supporting documentation to ascertain eligibility and coverage (Zhang et al., 2019). This review procedure often takes a few weeks, during which the insurer may ask the healthcare practitioner for more details or clarification. To prevent delays, prompt responses from all stakeholders are essential (Zhang et al., 2019). Following acceptance, the insurer will handle the claim and send Ms. Johnson’s healthcare provider a check for the approved medical costs following the policy’s provisions. The healthcare provider will then send Ms. Johnson a bill for any outstanding balance, which she might be accountable for depending on her insurance’s deductible and copayment conditions.
In conclusion, a covered person requesting a qualifying medical service initiates a medical insurance claim. A successful claims settlement procedure depends on the timely submission of the claim and strict adherence to deadlines. Meeting these deadlines guarantees that the covered party will get the money they need for medical bills while preserving the reliability of the insurance system.
References
Worth, R. M., & Mytinger, R. E. (1996). Medical insurance claims as a source of data for research: accuracy of diagnostic coding. http://hdl.handle.net/10524/54128
Zhang, H., Yin, Y., Zhang, C., & Zhang, D. (2019). Costs of hospitalization for stroke from two urban health insurance claims data in Guangzhou City, southern China. BMC health services research, 19, 1-12. https://doi.org/10.1186/s12913-019-4530-2
