Medical billing and claims is the work of turning a patient's treatment into a bill, and of getting that bill paid by the patient's insurer. A bill sent to an insurer is called a claim. Every claim has two ends: the hospital or clinic that sends it, and the insurer that checks it and pays it. This page describes both ends, in two very different markets.
The first market is the United States. There, most medical bills are paid by health insurers and government health plans. Americans call them payers, and they call the doctors, clinics and hospitals that treat patients providers. The provider must turn each visit into standard medical codes: one code for each diagnosis, and one code for each thing the doctor did. The insurer's software checks these codes before it pays. When an insurer refuses to pay a claim, this is called a denial, and the provider must correct the claim or appeal against the decision.
Say a retired bus driver in Seattle sees a doctor about chest pain. Weeks later, the clinic is still waiting for his insurer to pay. In between, someone has coded the visit, sent the claim, and answered the insurer's questions about it. This paperwork employs hundreds of thousands of people. A large share of them work in India, in coding and billing centres in Chennai, Hyderabad, Bengaluru and Delhi. Much of the software for both ends is also built in Indian engineering centres.
The second market is India itself. Here, most insured patients use a cashless claim. The hospital asks the insurer for approval when the patient is admitted, and the insurer pays the hospital directly after discharge. Imagine a teacher in Indore admitted for gallbladder surgery. She shows her health insurance card at the hospital's insurance desk, and she pays only for the items her policy does not cover. Often a third-party administrator (TPA), a company licensed by IRDAI to process claims for insurers, handles her claim. Ayushman Bharat PM-JAY, the government scheme for poorer families, pays hospitals in a similar way. More and more of these claims pass through the National Health Claims Exchange (NHCX), which carries every claim in one standard format.
The page has two zones, one for each end of the claim.
The first is provider billing. A revenue cycle management (RCM) system tracks each bill, from the check of the patient's cover to the final payment. A healthcare clearinghouse delivers each claim to the right insurer. AI medical billing agents now draft the codes, the claims and the appeals.
The second is health insurance claims processing. The insurer's health plan administration system holds its members, its plans and its contracts with providers. Claims editing software checks the codes, claims adjudication decides what to pay, and healthcare payments sends the money. Before some expensive treatments, the insurer must also give prior authorisation.
On both ends, AI models now draft much of the work. A model on the provider's end writes the claim or the appeal. A model on the insurer's end reads it and drafts a decision. A person checks the cases that matter. This arrangement is called human in the loop, and many of those people work in India.