Medical claims examiners review health insurance claims to ensure their validity and protect insurance companies from fraud. They handle paperwork, review supporting documents, and may interview medical experts to determine if treatment is appropriate. If fraud is suspected, they may contact special investigators.
The primary task of a medical claims examiner is to confirm the validity of health insurance claims. Insurance companies often need this type of specialist to protect the company from fraud while ensuring that customers receive the medical care they need. The typical medical claims examiner can expect to deal with a lot of paperwork because he or she must carefully review the details of each claim to ensure that the treatment received is appropriate for the reported medical problem. If there is any doubt, medical claims examiners may need to arrange interviews with medical specialists so that they can clear up any confusion. If fraud is suspected, claims examiners may need to do more research with the help of special investigators.
Most medical claims examiners deal with paperwork regularly and are expected to handle several claims a day. Each claim usually comes with supporting documents, such as medical records and hospital bills, and examiners need to examine each file carefully. In most cases, all of the information needed to close the claim is included in the initial files, but examiners are sometimes required to request additional documentation. This is especially true when some details of the claim don’t make sense and examiners need to figure out if an error was made or if the patient or doctor is trying to commit insurance fraud.
When the information included in a claim does not add up, and additional documents do not help, examiners may need to interview medical experts. For example, if a patient’s claim includes medical records and bills that show complicated and expensive treatment for a simple, minor medical problem, a medical claims examiner would be expected to discover the rationale. In many cases there is a valid reason for the high costs; other times, the patient’s medical team is simply trying to get more money from the insurance company. At this time, the medical claims examiner usually conducts interviews with unbiased medical professionals to find out the appropriate treatment for the patient’s condition, because this may determine whether the insurance company should pay the claim.
If interviews show that treatment may have been unnecessary, the Medical Claims Examiner may contact special investigators for more information. The purpose of the investigation will be to find out whether the hospital or the patient is trying to commit insurance fraud with forged documents and misleading information. In this case, the claim will be denied and legal action may be required. If the investigation shows that the claim is indeed valid, it will be paid and the case closed.
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