The seven elements of a payable claim

Healthcare providers are obligated to comply with a wide range of statutory and regulatory requirements associated with the provision, documentation, coding, and billing of a medical claim. It is important to keep in mind that the viewpoint of an outside auditor is not going to be the same as that of the treating physician. For instance, when documenting medical services, the information viewed as most significant (and therefore recorded) by a treating physician may be very different from the information an outside auditor hopes to glean from a patient's record. As a result, a significant disconnect between the parties may occur. To avoid this, it is essential that a treating physician or other healthcare provider diligently work to help ensure that claims submitted to Medicare, Medicaid, or a private payer fully comply with all applicable coverage and payment requirements. We have developed a checklist that we refer to as "The Seven Elements of a Payable Claim" to assist providers in this effort.