How Do Medical Billing Services Integrate With Insurance Policies?

Doctor calculating expenses

Medical billing services are a tedious and time-consuming process. Billing is the last step to encountering clients in most industries and businesses. A medical billing process begins with patients’ information but does not end with the last day of patients’ visits. A medical billing process is completed when the account receivable reaches zero, which is possible only when all the reimbursements from the payers are covered and received. The process is not as simple as it is written in the above statement. This is the most complicated process and deals with different types of insurance, causing considerable hassles. In order to understand the relationship between insurance and best medical billing services, we must understand what insurance itself is.

Insurance coverage and its features

Insurance is a legal convention between two parties, known as insurance coverage or insurance policy. An insurance policy is a financial protection contract between two parties, and it covers the financial risks of an individual due to unforeseeable occurrences.

Insurance coverage silent features are mentioned below

  • It is a plan to manage risk by using an insurance policy against uncertain loss.
  • Insurance coverage is provided for medical expenses, vehicle damages, property loss damages, etc.
  • The main component of an insurance policy is premiums, deductible, and policy limit.

Medical Billing Insurance

Medical billing insurance is a process of submitting claims and taking follow-ups on the payment of services provided by healthcare providers. Once a claim is submitted, a medical biller has to follow up and receive reimbursement for it.

Various types of health insurance plans

There are multiple health insurance plans available in the medical billing services California, and it is a patient/ client choice which plan to choose based on the benefits.

Types of health insurance plans

  • Preferred Provider Organization plan(PPO)

With a PPO plan, you have access to a network of medical professionals for your treatment. The plan members’ care will be provided by these providers at the agreed-upon rate.

  • Point of service plan (POS)

In the US, a managed care health insurance plan is referred to as a point-of-service plan. It combines the traits of a preferred provider organization and a health maintenance organization.

  • Health Maintenance Organization plan (HMO)

HMOs have a network of physicians, medical facilities, and other healthcare professionals that have consented to take payment at a predetermined level for any services they render. The HMO can reduce costs for its members as a result.

  • Exclusive provider organization plan (EPO)

Exclusive provider organizations (EPOs) are a type of hybrid health insurance where a primary care physician is not required but where healthcare professionals are only allowed to see patients within a specific network. Visits require prior authorization and no out-of-network care is offered.

  • Health saving account -qualified plan (HSA)

A health savings account, sometimes known as an HSA, is a type of savings account where you can place pre-tax funds aside for medical expenses. Saving money might help you pay for medical bills while lowering your taxable income.

  • Indemnity plans

A health savings account, sometimes known as an HSA, is a type of savings account where you can place pre-tax funds aside for medical expenses. Saving money might help you pay for medical bills while lowering your taxable income.

Preferred provider organization plan (PPO)

This is the most common insurance policy provided by employers. According to the Kaiser Family Foundation (KKF), 47% of individuals use this type of insurance. In a PPO plan, Employees are motivated to use a network of recommended practitioners and hospitals to cater their medical needs at a discounted or negotiated rate. Employees meet their annual deductible before the health insurance companies start to cover their medical bills.

Advantages of the PPO plan

  • You can choose any primary care practitioner and other healthcare facilities within your insurance company’s network of providers.
  • Covers some out-of-network costs as well  
  • You are able to see a specialist without a primary care physician’s reference. 

Disadvantages of the PPO plan

  • Higher monthly premiums
  • Have to pay the deductible cost; the money has to be paid out of pocket before the insurance covers anything.
  • Deductibles can range from $1,701 to $ 4,000

FQHC Billing

An FQHC billing service can help you receive reimbursements from the government for your medical services provided under the FQHC program. If you want help keeping track of bills and payments, an FQHC billing service can make sure everything is properly paid and filed correctly with Medicare or Medicaid so that you don’t get any penalties from them for late payment or noncompliance with their regulations.

Health Maintenance Organization plan (HMO)

Next is the health maintenance organization (HMO) plan. In these plans, providers offer a contract for a wide range of healthcare services, particularly with the HMO. HMO plans usually suggest choosing a primary care doctor, and the employees usually get a frame of reference from their PCP to visit a specialist. One of the advantages of an HMO is that it provides broader coverage for preventive care than other policies. Usually, employees do not need to pay a deductible before coverage. Remember that HMO plans do not cover employees who visit doctors outside their network of doctors.

Advantages of the HMO plan

  • You get a plan without a deductible
  • A low premium
  • You get a primary care physician for your medical needs
  • You get a lower out-of-pocket cost for prescription

Disadvantages of the HMO plan

  • You get less flexibility in choosing a practitioner or healthcare facility
  • For any emergency visit, you cannot get care from outside of your network.
  • It would help if you had a referral from a primary care physician to visit a specialist.

Point of Service Plan (POS)

A POS plan combines the features of an HMO and a PPO plan. The POS plan, like an HMO, requires employees to choose a primary care practitioner from the plan’s network of providers. Employees who use services referred by PCP may get a higher level of coverage.

Advantages of the POS plan

  • You get flexibility while choosing physicians and the providers
  •  For coordinated care, you get a primary care physician

Exclusive Provider Organization plan (EPO)

EPO plans are like HMO plans because the members of the EPOs have network physicians except in emergencies. Members are facilitated by PCP, who provides references for network specialists, and members are managed with a small co-payment and a deductible.

Advantages of the EPO plan

  • If you have a balance of fewer providers, choose a lower rate of exchange
  • You can get value with the smaller panel of providers

Health saving account qualified plan (HSA)

An HSA plan is a tax-advantaged savings account with an HSA-compatible high-deductible health plan (HDHP) to pay for medical expenses. HSAs are attached with group health insurance coverage; employers must add into the account whether they are offering a group policy or not.

The advantages of an HSA plan

  • You have HDHP and need help bearing out-of-pocket expenses
  • You have control over how to save or spend money
  • ‘You have a tax-free contribution to an account

Disadvantages of an HSA plan

  • You have deductible costs, which means you have to pay out-of-pocket before the insurance covers anything.
  • HSA is exclusively meant for medical expenses.

Indemnity Plans

Indemnity plans are considered fee-for-service plans. For this reason, insurance companies need to pay a specific percentage of the customary charges. In indemnity plans, no network of providers is available, so patients are free to choose their physicians and hospitals. The insurance provider defines the service fee and changes from physician to physician.

The Advantages of Indemnity Plans

  • You don’t need to commit to one specific primary care physician.
  • You can see a specialist without a referral from primary care.
  • You are flexible in choosing physicians and healthcare centers.

Disadvantages of an indemnity plan

  • It is expensive insurance depending on where you live, your age, and what other benefits you are demanding

Medcare MSO deals with all types of insurances

Medcare MSO is the best medical billing company with skilled and certified medical billers and coders who deal with all types of insurance in medical billing services. The staff of Medcare MSO tries to maximize reimbursement and minimize denials. It has advanced technology and skilled & professional human resources that can deal with all types of insurance and give the best output in medical billing services. 

Our billers have exceptional knowledge and are up-to-date with the latest insurance regulations. Coding staff always give proper attention to gathering information related to patients, try to reduce human errors, and minimize denied claims. It provides outstanding medical billing services to cut down on costs and increase productivity. Medcare MSO is HIPAA compliant, completely and continuously updates the latest codes for ICD-10 CM, CPT, PCS, and HCPCS. For further details, contact Medcare MSO Podiatry Billing through email at

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The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of The World Financial Review.