A medical claims examiner’s primary responsibility is to verify the validity of health insurance claims. This type of specialist is frequently required insurance companies in order to protect the company from fraud while also ensuring that customers receive the medical care they require. Because he must carefully examine the details of each claim to ensure that the treatment received is appropriate for the medical issue reported, a typical medical claims examiner can expect to deal with a lot of paperwork. If there are any doubts, medical claims examiners may need to schedule interviews with medical specialists to clear things up. If fraud is suspected, claims examiners may need to conduct additional research with the assistance of special investigators.
Most medical claims examiners deal with paperwork on a daily basis, and they are expected to work on multiple claims per day. Each claim is frequently accompanied supporting documents such as medical records and hospital bills, and examiners must carefully review each file. In most cases, the initial files contain all of the information needed to close the claim, but examiners may need to request additional documentation. This is especially true when some aspects of the claim are illogical, and case examiners must determine whether a mistake was made or if the patient or doctor is attempting to defraud the insurance company.
When a claim’s information doesn’t add up and additional documents don’t help, claims examiners may need to consult with medical specialists. A medical claims examiner is expected to find out why a patient’s claim includes medical records and bills that show complicated, costly treatment for a minor, simple medical problem. In many cases, the high costs are justified; in others, the patient’s medical team is simply attempting to extract more money from the insurance company. The medical claims examiner then typically conducts interviews with unbiased medical professionals to determine the treatment that would be appropriate for the patient’s condition, as this will determine whether the insurance company is required to pay the claim.
If the medical claims examiner determines that the treatment was unnecessary based on the interviews, he or she may contact special investigators to learn more. The goal of the investigation will be to determine whether the hospital or the patient is attempting to defraud the insurance company falsifying documents and providing false information. If this is the case, the claim will be rejected, and legal action may be necessary. If the investigation reveals that the claim is legitimate, it will be paid and the case will be closed.