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Medical Insurance Coverage and Attorney Representation

admin — Fri, 24 Apr 2009 14:02:00 +0000

Medical Insurance Coverage and Attorney Representation

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The United States federal government has sponsored several social insurance programs that give benefits to qualified citizens. These programs are designed all for giving benefits and protection to well-qualified sectors of society. The classic example of these programs includes the Social Security, Medicare, the Pension Benefit Guaranty Corporation (PBGC) program, the railroad retirement program and the state-sponsored unemployment insurance programs.

This article will mean to explain in a comprehensible manner all about medical insurance (Medicare). Specifically the article will tackle basic points regarding the coverage of this social insurance program of the federal government including the value of Attorney representation and guidance in matters of claims, coverage and complaints.

All about Medical Insurance Program (Medicare)

I. History

Medicare is a social insurance program administered by the United States government that insures indigent recipients. The Medicare as well as its companion program Medicaid is signed into law by President Lyndon Johnson as amendments to Social Security legislations. Later on, up until now, this program had undergone series of changes and overhauling. The changes relates to the features, coverage and exact definition of covered citizens who may come to avail of this social benefit.

Originally, Medicare program has two parts, that is: Part A (Hospital Insurance), and Part B (Medical Insurance). Later on, with the changes, Medicare Part C and Part D were introduced extending more benefits and comprehensive health insurance protection to the aged, disabled, and those with end-stage kidney disease.

II. Eligibility

Medicare is a Health Insurance Program for:

People age 65 or older
People under age 65 with certain disabilities
People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

III. Parts of the Medicare program

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As laid above, the original Medicare program is composed of Parts A and B. However, with the passing of time, the coverage was broadened having introduced Parts C and D.

In brief, the Medicare Plans are composed of the following:

Medicare hospital insurance (Part A) helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.
Medicare medical insurance (Part B) helps pay for physician services, outpatient hospital services, outpatient physical therapy, other medical services that are medically necessary, and supplies and equipment that are covered by Part A.
Medicare Advantage Plans (Part C) are plans offered by private companies that contract with Medicare to provide all Medicare Part A and Part B benefits. This has been constituted with the passage of the Balance Budget Act of 1997. Medicare Advantage Plans gives beneficiaries the option to receive their Medicare benefits through private health insurance plans instead of through the original Medicare plan (Parts A and B). Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. Some plans also offer prescription drug coverage.
The Medicare Prescription Drug Benefit (Part D) provides outpatient prescription drug coverage for the aged and disabled. This went into effect on January 1, 2006. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). Unlike Original Medicare (Part A and B), Part D coverage is not standardized.

IV. Medicare situations and facts

The issue of dis entitlement of Medicare has been the constant problems of most claimants, since the inception of this social insurance program. On several occasions, contentions respecting claims dis entitlement beset administrative agencies tasked to implement the program.

It is accounted for dis entitlement happened because of lack of proper guidance and representation in claiming this federal benefit. Most claimants have no real inkling on the mechanics of proper claims including its substantiation. To say, the lack of proper guidance of a Medical Insurance Attorney is wanting.

V. Attorney representation

Everybody wants to get the most of social security benefits including the Medical insurance and Medicare coverage. However, this can hardly be attained when proper guidance and representation of a Medical Insurance Attorney is lacking.

Just like any other claims for benefits, medical insurance claim needs to undergo considerations of a good lawyer. In order to harness a substantial claim that is both viable and workable, an adeptly qualified lawyer is required all for leading to a successful benefit claims.

Our experienced social security lawyers are knowledgeable with medical insurance and other related issues. To avail of our expert services, you can visit our website and have a free case analysis.

Medical Insurance Claims

admin — Tue, 24 Feb 2009 14:02:00 +0000

Medical Billing and Insurance Claims

Medical billing services help in dealing with insurance claims you make related to your healthcare expenses. Read this article to know about medical billing services and insurance claims.

The term medical billing refers to the process of submitting claims to the insurance companies and following them in order to collect payment for the services delivered by a healthcare provider. One can start his/her medical billing services to provide billing and collection to the providers. Many of the providers depend on medical billing services for processing claims to insurance companies (payer), instead of claiming themselves.

A patient visits a healthcare physician for medical checkup or treatment. The patient gives information on his/her personal details (age, sex, location, etc.) and about the insurance company that he/she has taken up the medical policy. The doctor updates the medical record of the patient for further diagnosis, examinations, test, medications and treatment (if any). The information provided by the patient about the policy can be confirmed by contacting the payer.

A qualified staff examines the medical record and translates into certain procedural and diagnosis codes. The medical billing company analyzes the data and performs services for the provider. Either medical billing services handle claims only or take care of both claims and billing. It is not easy to settle a medical insurance claim. The billing company has to bill the claim amount and fill up the claim form. Filling the claim form should be done carefully; even a single mistake on the part of the patient’s details or treatments can lead to rejection and returning of the claim. Information in the claim should match with that in the policy document. Regarding any doubt, the billing company can verify with the patient and the provider.

The claim is then submitted to the respected insurance company in which the patient has a policy with. In some cases, the claim has to be submitted to a clearinghouse before submitting to the payer. Insurance company will further process the claim. If there are no mistakes, it determines the allowed charge payable for each service depending upon the patient’s policy and accordingly, payment is done. Thus, a medical claim is settled.

The medical billing services charge fee to the provider for their services. Some medical billing services charge their fees according to the number of claims handled, whereas some prefer to charge for a percentage of what they collect.

Majority of the medical billing services use electronic billing system with advanced medical billing software. All the major tasks like filling up the claim forms, submitting claims and sending billing statements are done via the Internet. The advantages of using electronic billing service are it saves time and increases efficiency and profitability.

Everyone must be aware about various health insurance schemes and their significance. Majority of the American citizens have medical insurance cover, which can be in the form of dental insurance, individual health insurance or family health insurance. One can take up disability insurance according to the lifestyle and risks involved. While taking up any insurance, it is very important for all the policyholders to have detailed information about the policy he/she has taken. One should analyze the policy documents and understand the coverage that comes under the particular scheme.

Certain problems may arise related to the claims submitted via the billing services and the insurance company’s payment. In such conditions, the cooperation of the patient is very important. He/she should give detailed information about the policy such as coverage of the policy and policy terms. If possible, the patient should call up the insurance company and inquire about reasons for denial. If the insurance company denies the claim, then the patient has to pay the medical bill to the provider. For genuine reasons, the patient can file an appeal against the insurance company.

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By Ningthoujam Sandhyarani

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