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 :)
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!
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.
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 🎉❤
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
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 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.
@@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!
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!
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
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.
@@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
Hi Eric - Thanks for the video. What do you think about RxSense that is replacing Cobalt programmed systems? RxSense as a SaaS. It evaluates and processes claims with accuracy and in compliance. It also processes the claims in real time instead of batch processing claims like overnight and eliminate limitations like system strain. I heard it also supports all sorts of pricing models like transparent pricing, reference based pricing, and spread pricing. It analyzes and reports on utilization, member outcomes, cost trends - like we need to know measurement and further analyze how healthcare services, resources, and medications accessed and used by specific populations. I heard it can be customized with different formularies, benefit design, and networks. It also can be integrated with pharmacies, pharmacy companies, and other healthcare companies. Would love it if you could do a video cross comparing the different SaaS solutions out there!!
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.
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 🌟👍🏻
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!!
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.
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.
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 😀
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.
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 😃
Super! Thank you for watching!!
You desire a teach of the year on TH-cam. You explain things so well. 😂🎉
Thank you.
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 :)
Super! Glad you liked it. Thank you for watching.
Hi@@ahealthcarez
All heros don't wear capes, some wear a tie.
Thanks for that super simple explanation.👍🏻
Thank you for your kind comment.
LOVE your simple yet excellent explanation. Thank you for sharing your knowledge with us!
Thank you for watching!
you are my favorite new nerd on TH-cam! thanks for the stellar content
🤣🤣Thank you for watching!!
I love this comment 😭😂😂
Thanks for your explanation. O started to work for a medical company and there are a lot on concepts that I need to understand
Thank you for watching and for your comment!!
Hi, great video! Could you help to find the slide presentation by Aetna mentioned in the video?
Would be really interesting to see the exact auto adjudication levels for each carrier.
#Agreed.
Great explanation. Thanks
Thank you for watching and for your comment.
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!
Thank you for pointing that out. I have added the link in the video description.
@@ahealthcarez Thank you very much!!
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.
Thank you for sharing your experience.
This is great!!! This isn’t boring at all!!
You’re my kind of viewer! Thank you.
really appreciated. can you shard the link the aetna slide on claim adjudication?
Thanks Dr.Bricker. the link in the doesn't work.
Thank you for letting me know.
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 🎉❤
Do we know the percentage of F.W.A of the total claims paid?
Some estimates as high as 10% per Marshall Allen article in ProPublica. Thank you for watching.
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
Is this the same situation for self funded companies that use TPA's services to adjudicate in the USA?
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. .
Thank you for your feedback.
What does it mean when a claim is contested?
They don’t want to pay it.
@@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.
@@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!
@@alecnicolaysen9972 thank you so much for your explanation. It well understood!!
It may have went through, but trust they will catch it and retract it.
Thank you for watching and sharing your thoughts.
This was great. Mind uploading a video on authorizations. Thank you
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!
Thanks for the video. I’m wondering where does the medical necessity checkup come in play?
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
What is threshold in high dollar claim, if I have to audit high dollar claim then how to calculate threshold amount
Please explain in detail with example
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.
@@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
Hi Eric - Thanks for the video. What do you think about RxSense that is replacing Cobalt programmed systems? RxSense as a SaaS. It evaluates and processes claims with accuracy and in compliance. It also processes the claims in real time instead of batch processing claims like overnight and eliminate limitations like system strain. I heard it also supports all sorts of pricing models like transparent pricing, reference based pricing, and spread pricing. It analyzes and reports on utilization, member outcomes, cost trends - like we need to know measurement and further analyze how healthcare services, resources, and medications accessed and used by specific populations. I heard it can be customized with different formularies, benefit design, and networks. It also can be integrated with pharmacies, pharmacy companies, and other healthcare companies. Would love it if you could do a video cross comparing the different SaaS solutions out there!!
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.
Thank you for your feedback.
@@ahealthcarez You are very welcome
Wow great explain
Thank you for watching and for your feedback.
Any vacancies?
Great video, I’m looking on a training on NASCO platform for healthcare claims, any suggestions? Thanks
I need to want more details for claim adjudication process.This is use to improve my knowledge to learn process quickly.
Thank you for this video
You are welcome. Thank you for watching!
COBOL!????
Yes, COBOL.
🔥😎 awesome sir
You are kind. Appreciate the feedback.
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 🌟👍🏻
Thank you for watching and for your comment!!
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!!
Thank you for watching and sharing your thoughts.
What are you talking about greet exist and more places than just the United States.
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.
Thank you for sharing your thoughts.
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.
Thank you for watching and for your comment!
$10,984? C'mon, they knew the logic for the adjudication like they were the Astros stealing signs. Flagrant!
Thank you for watching and for the comment.
super excited for this boring topic!
Glad you are. I am too! 😉
This is amazing
You are kind. Appreciate your encouragement.
How many cups of coffee did you drink this morning?
I have one… but it’s big. 😉 Thank you for watching.
I enjoyed this
Thank you for your feedback.
another banger!
Thank you for your feedback.
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
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 😀
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 🥰
At least a couple of misspellings on your white board: submitted not submitted + timely not timly.
Thank you for your feedback.
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.
Hi, we are medical billing company in India, can you share you emails for further talks