June 21, 2023

You head to the doctor for a routine appointment. A claim is born! But what happens between the time of your medical service and when you receive a bill or explanation of benefits (EOB)? This week’s episode of “Under the Coverage,” discusses a medical claim’s journey in the health care delivery system.

This week’s podcast, “The Life of a Medical Claim,” features guest Barb Glor, who is director, claims at Nova and has more than 20 years of experience in the health benefits industry.  For those who are not familiar with the terminology, Glor offers this definition of a claim:

“Simply put, a claim is a request for payment that either you or your health care provider submits to [your third-party administrator (TPA)] or your insurance carrier when you have services, anything from routine office visits to an inpatient stay and everything in between that.” 

What happens next isn’t always a simple process but having a baseline understanding of how a claim gets processed might help you gain insight into industry timelines and requirements. In general, the administrator or insurer reviews the claim and approves or denies it. If approved, payment is sent directly to the provider. If it’s denied, there may be some commons reasons – such as the provider is out-of-network for the health plan, there is an invalid code, or the diagnosis code doesn’t align with the procedure code (the services the provider is billing for). 

The adage “prevention is the best medicine” also applies to health insurance. As past podcast guests have advised, Glor recommends people get a summary of benefits from their employer to have a better understanding of their coverage or call their insurer’s customer service team before having medical services rendered. This can save on costs and confusion.

For more, listen to the latest podcast, “The Life of a Medical Claim.”

In 2022, Nova launched “Under the Coverage,” a podcast featuring people who spend their working days focused on health benefits and health care, to share their insider tips and information they wish every health care consumer knew.

How to Listen

New episodes – each 15 minutes or less! – are added regularly and are available on SoundCloud, Stitcher, Spotify, Apple Podcasts, Google Podcasts, Pandora, Amazon Music and TuneIn. You can also listen via digital assistants like Alexa, Google and Cortana. Just ask Alexa to, “play the Under the Coverage podcast on Apple Podcasts” (or wherever you get your podcasts).

Have an idea for a future episode or a question you’d like answered? Find Under the Coverage on Twitter @UndrTheCoverage or email podcast@novahealthcare.com.