Health Insurance Claims Adjudication

[@dudoji85]

Thank you so much for these videos. I work in a Top10 Pharma, and these videos are so much more helpful than our company trainings 😃

[@ahealthcarez]

Super! Thank you for watching!!

[@lawron2]

You desire a teach of the year on KZbin. You explain things so well. 😂🎉

[@ahealthcarez]

Thank you.

[@privatestudioSS]

All heros don't wear capes, some wear a tie. Thanks for that super simple explanation.👍🏻

[@ahealthcarez]

Thank you for your kind comment.

[@thelichbeats]

You summed it up in a way that my professors couldn't and now I have a better understanding of the basics of adjudication! Thanks for the video, it's an amazing supplement for learning :)

[@ahealthcarez]

Super! Glad you liked it. Thank you for watching.

[@immushaik4592]

Hi​@@ahealthcarez

[@edgaruriel9565]

Thanks for your explanation. O started to work for a medical company and there are a lot on concepts that I need to understand

[@ahealthcarez]

Thank you for watching and for your comment!!

[@bdpatton2]

you are my favorite new nerd on KZbin! thanks for the stellar content

[@ahealthcarez]

🤣🤣Thank you for watching!!

[@LynnzeyLynn]

I love this comment 😭😂😂

[@lananhnguyen7415]

LOVE your simple yet excellent explanation. Thank you for sharing your knowledge with us!

[@ahealthcarez]

Thank you for watching!

[@michaeljuergens302]

Would be really interesting to see the exact auto adjudication levels for each carrier.

[@ahealthcarez]

#Agreed.

[@jiezhu8745]

Hi, great video! Could you help to find the slide presentation by Aetna mentioned in the video?

[@AggresivelyBenign]

This is great!!! This isn’t boring at all!!

[@ahealthcarez]

You’re my kind of viewer! Thank you.

[@DeeDee-lr8nb]

It may have went through, but trust they will catch it and retract it.

[@ahealthcarez]

Thank you for watching and sharing your thoughts.

[@mrsbootsworkouts]

Great information! Difference payers have different process, but basicallly accurate. And yes, there’s still COBOL :). And yes, a lot of waste and abuse is going through unfortunately from Providers that cause the rates to go up for everyone.

[@ahealthcarez]

Thank you for sharing your experience.

[@spartanzevil8968]

I need to want more details for claim adjudication process.This is use to improve my knowledge to learn process quickly.

[@antoniocampos8049]

Great explanation. Thanks

[@ahealthcarez]

Thank you for watching and for your comment.

[@roy_abir33]

Excellent explanation. Step wise you have made it clear your each point and also it was made interesting to learn because you backed up the information with sone real time example. Thank you for the video 🎉❤

[@MarkStanley57]

At 1:25 you reference a slide presentation and mention there will be a link in the show notes, but I don't see the link. Am I missing something? Thanks!

[@ahealthcarez]

Thank you for pointing that out. I have added the link in the video description.

[@MarkStanley57]

@@ahealthcarez Thank you very much!!

[@michaelli4981]

really appreciated. can you shard the link the aetna slide on claim adjudication?

[@krishvanbhavi]

Sir thank you so much of this adjudication video . I need to clarification of adjudication could you please explain that flow chart it's should be very useful to me please

[@jimmie-satx]

This video was great. I have a unique scenario about discriminatory exclusions for a certain procedure and I have an uphill battle on this one. I do like a challenge though (My law professors see that and love it) so I am taking on Cigna at the moment. Should be interesting. .

[@ahealthcarez]

Thank you for your feedback.

[@TheTruthSeeker756]

I'm for government run healthcare where every one has to pay, like they do now with private insurance. Nothing for free. Except the money won't be going to all the insurance executives who add no value at all to people's health. Doctors will decide the claims, not people who have no medical training making decisions on people's health. Anyone working in this industry should have to have required rigorous certifications. This is serious stuff that should be left to experts and not business hacks.

[@ahealthcarez]

Thank you for sharing your thoughts.

[@WR4TH13987]

Is this the same situation for self funded companies that use TPA's services to adjudicate in the USA?

[@menoldomare4015]

This was great. Mind uploading a video on authorizations. Thank you

[@ahealthcarez]

Thank you for watching and for your comment. There already is a prior authorization video on AHealthcareZ… just use the search bar. Appreciate your interest!

[@smehrabi]

Thanks Dr.Bricker. the link in the doesn't work.

[@ahealthcarez]

Thank you for letting me know.

[@DJStrengthinfinesse]

Do we know the percentage of F.W.A of the total claims paid?

[@ahealthcarez]

Some estimates as high as 10% per Marshall Allen article in ProPublica. Thank you for watching.

[@AlJahhaaf]

Thanks for the video. I’m wondering where does the medical necessity checkup come in play?

[@satyamkamal5678]

Like whenever policy is about to expire or like some code doesn't cover under the policy but after request by the patient company will pay that claim that's the medical necessity for that they have something specific remark codes

[@SanjayKumar-vx8pg]

Wow great explain

[@ahealthcarez]

Thank you for watching and for your feedback.

[@HammyZia]

Great demonstration. I have been following you on youtube and linkedin and further subscribed your news letter. I must say that you give immaculate explanation of every thing. Is it possible if you can do a 1 minute video presentation for my company? I will pay you for it? I need a doctor to present my firm for promotion.

[@ahealthcarez]

Thank you for your feedback.

[@HammyZia]

@@ahealthcarez You are very welcome

[@3713msg]

Only in the USA, Land of Corporate Greed, would something like this even exist. Stick it to The American People, for simply trying to stay healthy. Unreal!!

[@ahealthcarez]

Thank you for watching and sharing your thoughts.

[@JChan-ru2hf]

What are you talking about greet exist and more places than just the United States.

[@Lizeth9.9]

Thanksssss super helpful video! Right now am in school for Administrative Medical Assistant and RTA Is in my book. I was confused, but thanks a million! I understand it perfectly now with you better thank my teacher and book 🌟👍🏻

[@ahealthcarez]

Thank you for watching and for your comment!!

[@yallseeyeah]

What does it mean when a claim is contested?

[@ahealthcarez]

They don’t want to pay it.

[@yallseeyeah]

@@ahealthcarez can you please elaborate a little more on the process? Thank you. I would believe when the insurance don’t want to pay is denied and we have to submit an appeal.

[@alecnicolaysen9972]

@@yallseeyeah insurance companies ("payers") have a few things in common. One of those things is "timely filing" which is the amount of time - the deadline - that a provider has to submit the claim to the payer after they gave care to the patient. The timely filing limit varies by payer. For example, timely filing is 365 days from the date of service for Medicare, but only 60 days for a popular nationwide commercial insurance plan. You must submit your claim prior to the timely filing deadline or your claim is voided. If you submit the claim, and the payer pays it, then either the story ends there or the claim is forwarded to the next payer in the filing order (if the subscriber has multiple coverages). That, or if there is a remaining balance for the patient to pay - that is legally allowed to be collected - then the provider may pass the bill along to the patient, if they so choose. By the flip side of the coin, if you submit the claim and the payer does NOT pay it, then they are either (a) denying the claim, or (b) rejecting the claim. If they reject the claim, it's because they could not load it into their system (e.g., wrong file format causing system to error). If the payer rejects your claim, it's the same as them saying they never received it. If the payer DENIES your claim, however, then they are required to give reason(s). These reasons are explained with standardized codes, called "Claim Adjustment Reason Codes" (CARCs) and "Remittance Advice Remark Codes" (RARCs). These are also referred to by some as EOB (Explanation of Benefits) Codes. If the payer denies your claim, you have the option to try and appeal the decision/appeal the claim. This is done by resubmitting a corrected claim that references the previous claim. Much like timely filing, there are also "appeal windows" that vary by payer. For example, one payer may allow 60 days after the adjudication decision date (the date of the claim denial) to submit an appeal, while another payer may allow 120 days. You can (attempt to) appeal a claim as many times as you like (unless otherwise stated in the provider-payer contract), however the appeal window does not reset with each re-appeal. Hope that helps!

[@yallseeyeah]

@@alecnicolaysen9972 thank you so much for your explanation. It well understood!!

[@youbizzhd683]

What is threshold in high dollar claim, if I have to audit high dollar claim then how to calculate threshold amount

[@youbizzhd683]

Please explain in detail with example

[@ahealthcarez]

Depends on how many claims you want to audit. Generally claims in excess of $20,000 in billed charges is a good place to start and analyze starting with the highest dollar claims and work downward.

[@youbizzhd683]

@@ahealthcarez yes sir thank you very much for the immediate assistance. ❤️ i also audited high dollar claims which was $5000. It was transferred by batch Oscar to high dollar Location. So I'm not getting the exact threshold amount of claim

[@lisaayala8274]

Great video, I’m looking on a training on NASCO platform for healthcare claims, any suggestions? Thanks

[@ChandraSekar-il2gk]

🔥😎 awesome sir

[@ahealthcarez]

You are kind. Appreciate the feedback.

[@jacoblittle4964]

COBOL!????

[@ahealthcarez]

Yes, COBOL.

[@whiteowl8594]

Thank you for this video

[@ahealthcarez]

You are welcome. Thank you for watching!

[@Mysterious8072]

Any vacancies?

[@paulramirez5668]

Hmm interesting. Thanks for that video. I wonder with the rise artificial intelligence which gets smarter the bigger the dataset (similar to how Facebook face recognition, once a user gets tagged enough, Facebooks algorithm automatically understands who they are in new photos) that this process can also see a huge benefit in that regard, especially with more complex claims.

[@ahealthcarez]

Thank you for watching and for your comment!

[@jkay07]

$10,984? C'mon, they knew the logic for the adjudication like they were the Astros stealing signs. Flagrant!

[@ahealthcarez]

Thank you for watching and for the comment.

[@josepaulloor6449]

This is amazing

[@ahealthcarez]

You are kind. Appreciate your encouragement.

[@bdpatton2]

super excited for this boring topic!

[@ahealthcarez]

Glad you are. I am too! 😉

[@CW-xf1li]

I enjoyed this

[@ahealthcarez]

Thank you for your feedback.

[@timbmd]

How many cups of coffee did you drink this morning?

[@ahealthcarez]

I have one… but it’s big. 😉 Thank you for watching.

[@channel_panel193]

another banger!

[@ahealthcarez]

Thank you for your feedback.

[@Aditya_Chopra980]

I am from India i want to do job in abroad any where. I am also working in uhc as a claims associate please help me sir

[@youbizzhd683]

Bhai we are not getting job in India after resigning from Indian Healthcare companies,how can client give us job directly with just knowing that you are capable or have experience in same field 😀

[@adekunlekolade4140]

Thanks so much for video 💯💓 I will like to Collab with you for ads I Don't know if you will have interest Awaiting for your awesome response 🥰

[@johnjacobs5766]

At least a couple of misspellings on your white board: submitted not submitted + timely not timly.

[@ahealthcarez]

Thank you for your feedback.

[@jasmineghaznavi4726]

You are sooo confusing as you are going very fast and not going into the main points. I wish you could Elaborate instead of summing. No learning from your videos. Please improve.

[@vikramsingh-ew3ew]

Hi, we are medical billing company in India, can you share you emails for further talks