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How Medical Claims are Becoming Fairer, Which is Good for the Insured

Posted: September 3, 2019 at 8:41 pm   /   by   /   comments (0)

The cost of healthcare in the U.S. is a continuing problem with medical costs far exceeding that of many other countries. So much so that international health insurance policies that exclude the United States are considerably cheaper than ones that don’t. This makes it clear how expensive U.S. based medical care is, along with the final settlement on medical billing too. 

With that said, work is in progress to avoid medical billing and health claims that are incorrect, fraudulent or indicate significant overcharging. Let’s look at how medical claims are becoming fairer.

The Difference Between Out of Pocket and Medical Costs Paid by a Third-Party

When it comes to paying for medical care, sometimes people pay out of pocket and other times a third-party like an insurer may cover the bill. When older, there’s also government health plans that may pay for healthcare costs too. 

For the individual payer, the problem is they have no way to know what is a reasonable price for the services they’ve received. They’re also not always in the best of health at the time, making it difficult to be objective. As a result, some healthcare providers may charge more than what would be normal and patients, despite thinking the bill seems excessive, may not be aware by how much. 

When a third-party pays for the care and deals with many such cases, they’re in a better position to aggregate the costs and have a clear sense whether the billing seems reasonable or excessive. They can compare similar treatment (like a broken arm) at hospitals in the same state or nationwide to see how prices vary and whether that makes good sense, or something looks questionable. 

The Problem with Medical Bankruptcies

If you think that medical costs are not a major concern for individuals, think again. 

Every year, over half a million American households file for bankruptcy due primarily to unpaid medical bills. Indeed, new research published on CNBC indicated that over 66% of bankruptcies were due to medical expenses. Even though the so-called Affordable Care Act was intended to make healthcare more accessible and affordable for everyone, especially the people who are least able to afford it, it hasn’t made a dent in the number of medical bankruptcies each year. 

Medical Claim Auditing is Helping

What a medical claim auditor does is review past and new claims for discrepancies, irregular items, excessive billing, fraud, and more. 

They now use sophisticated software that can break down a huge number of claims to look for things that are out of the ordinary and should be questioned. A medical claim auditor works on behalf of different organizations including healthcare consultants, insurers, physician groups and health plan providers to review claims and where appropriate, to request re-pricing and/or compensation where appropriate. They ensure that medical costs are correct and help stem the tide of medical inflation. 

For people who need medical care, the costs are surprisingly high. So much so that paying the bills can be difficult, even for people on a high income. Therefore, ensuring healthcare billing and insurance claims are fair is useful to keep healthcare providers honest and avoid egregious charges for medical care in the future. 

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