Final answer:
Claims submission is the transfer of claims data to payers, while claims adjudication is the process of reviewing claims for payment. Both are part of the healthcare reimbursement process which also involves issues like adverse selection in insurance markets.
Step-by-step explanation:
Claims Submission and Adjudication
The electronic or manual transmission of claims data to payers or clearinghouses is not called claims adjudication; rather, this process is known as claims submission or billing. Claims adjudication is the process by which a payer reviews a claim to decide on its validity and how much to reimburse the provider. The claim submission stage is crucial as it directly influences the adjudication process and the subsequent reimbursement to the healthcare provider. The transmission of claims is an integral part of the broader healthcare payment system, which includes various reimbursement models such as fee-for-service and health maintenance organizations (HMOs). Sharing digital records among health providers is essential for maintaining effective and integrated care, and also for establishing the necessary infrastructure to handle claims submission and adjudication.
Adverse selection is a related but separate issue that occurs in insurance markets when there is an information asymmetry between insurance buyers and insurers. This may influence the dynamics of insurance premiums and the provider's risk calculations. Overall, effective claims adjudication and insurance market stability are key for a sustainable healthcare system.