Medical billing might seem large and complicated than medical coding but it’s actually a process that’s comprised of eight simple steps.
The billing process of medical billing is simply stated as the process of communication between the medical provider and the insurance company. This is known as the billing cycle. The medical billing cycle can take in upwards of days to months to complete, and at times take several communications before resolution is reached.
Following steps of process are below:
- Register Patient:
When a patient calls to set up an appointment with a healthcare provider, they effectively preregister for their doctor’s visit. If the patient has seen the provider before, their information is on file with the provider, and the patient need only explain the reason for their visit. If the patient is new, that person must provide personal and insurance information to the provider to ensure that that they are eligible to receive services from the provider.
- Financial Responsibility:
Once the biller has the pertinent info from the patient, that biller can then determine which services are covered under the patient’s insurance plan. If the patient’s insurance does not cover the procedure or service to be rendered, the biller must make the patient aware that they will cover the entirety of the bill.
- Patient check-in & check- out:
When the patient arrives, they will be asked to complete some forms or confirm the information the doctor has on file. The patient will also be required to provide some sort of official identification, like a driver’s license or passport, in addition to a valid insurance card. Once the patient checks out, the medical report from that patient’s visit is sent to the medical coder, who abstracts and translates the information in the report into accurate, useable medical code.
This report, which also includes demographic information on the patient and information about the patient’s medical history, is called the “super bill.”
- Prepare claims:
The medical biller takes the super bill from the medical coder and puts it either into a paper claim form, or into the proper practice management or billing software. Once the claim is approved the medical provider is reimbursed based on a pre-negotiated percentage. Any rejected claims are sent back in the form of Explanation of Benefits or Electronic Remittance Advice.
- Transmit claims:
Billers may still use manual claims, but this practice has significant drawbacks. Billing electronically saves time, effort, and money, and significantly reduces human or administrative error in the billing process. Instead of having to format each claim specifically, a biller can simply send the relevant information to a clearinghouse, which will then handle the burden of reformatting those ten different claims.
- Adjudication of Monitor :
Once a claim reaches a payer, it undergoes a process called adjudication. In adjudication, a payer evaluates a medical claim and decides whether the claim is valid/compliant and, if so, how much of the claim the payer will reimburse the provider for. It’s at this stage that a claim may be accepted, denied, or rejected. Effectively, a claims appeal is the process by which a provider attempts to secure the proper reimbursement for their services. This can be a long and arduous process, which is why it’s imperative that billers create accurate, “clean” claims on the first go.
- Patient Statement :
Once the biller has received the report from the payer, it’s time to make the statement for the patient. Once the payer has agreed to pay the provider for a portion of the services on the claim, the remaining amount is passed to the patient.
- Follow up patient statement & collections :
The final phase of the billing process is ensuring those bills get, well, paid. Each provider has it’s own ways, set of guidelines, timelines. So you’ll have to refer to the provider’s billing standards before engaging in these activities.
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