Medical Billing Process

Medical billing Process is a chain of steps followed by medical billing experts to ensure that health care professionals are get paid for the health care services rendered to a patient. This chain of steps may differ slightly between medical billing offices.

Medical Billing Process also known with following familiar names:

• Medical Billing Cycle.
• Revenue Cycle Management – RCM.

Now let us know the chain of steps taken by billing experts also called as medical billing flow chart.

Patient Registration:

Whenever patient want to visit provider office to seek healthcare services, they must schedule a doctor’s appointment except in an emergency case.

Patient can schedule a doctor’s appointment either thru website or apps or call the clinic /doctor’s office or walk in. Billing expert’s collect the demographic and insurance information from the patient like Name, DOB, reason for visit, address, Active insurance details (primary, secondary and tertiary).

Once the billing expert collect the information, they create a patient account if it’s a new visit or update the existing patient account if it’s a return visit.

Insurance Verification/Authorization/Referral:

As per the insurance information collected from the patient at the time of appointment, billing expert will check through insurance websites or call the respective insurances to verify the benefits and coverage at the time of healthcare service. Also, during this process they verify authorization and referral required for treating as per the patient plan.

• If authorization required from an insurance company as per patient plan, then they obtain the authorization number.
• If referral required from PCP to consult specialist as per patient plan, then patient has to take a referral from PCP to consult specialist.

Finally, they verify the patient responsibility (Copay/coins/deductible).

If there are procedures or services that will not be covered as per the patient plan, then patient is made aware that they will be financially responsible for those charges.

Encounter:

At the time patient visit’s doctor office, patient should sign the following documents at front desk:

• AOB – Assignment of Benefits:  Patient authorizing the Insurance company to pay directly to provider for the healthcare services rendered.
• ROI – Release of Information: Release of Information is a document, signed by the patient authorizing the health care provider to release the patient health information to all those involved in medical billing process for reimbursing the claim.

Patient consult the doctor and gets treated for his health condition(disease) and in medical term we call this as an encounter.

Medical Coding (Diagnosis, Procedure and Modifiers):

Medical coder will convert diagnosed diseases into ICD code and procedure/treatment rendered by doctor into CPT & HCPCS code. Insurance company can only make a precise assessment if they have accurate codes (CPT, HCPCS and ICD) with modifiers.

Then, a report called a “Superbill” may be collected from all the data gathered thus far. The Superbill will contain following information

• Patient demographic and insurance information
• Provider and clinical information
• Medical history, information on the procedures and services performed (ICD, CPT, HCPCS codes, number of units, modifiers and authorization information).

Claim Generations:

A Superbill is used by Charge entry team as a primary source of data for creating claims. These claims will eventually be verified for accuracy, compliance and submitted to insurance company for reimbursement.

Charge entry teamwill enter the DX, CPT code, modifiers and an appropriate $ value as per the chosen CPT codes and corresponding fee schedule along with related information like date of service (DOS), number of units, quantity, authorizations (Referral or Prior).

Claim Submissions:

Claims can be submitted to an insurance company in two ways:

1. Paper or
2. Electronically

Paper Claim: CMS 1500 claim form sent manually to insurance company through post or mail.

Electronic Claim: Most of the insurances accept electronic claims and will be sent electronically with their respective insurance payer id via clearing house for reimbursement.

Claim Adjudication:

Claim Adjudication is the process by which insurance company assess claims and determine whether they are valid and compliant. Insurance team will check for errors in the claim which might not have been predictable by the clearing House.

During this claim adjudication process claim may be either accepted and paid according to the insurer’s contract with the provider or deny the claim with specific denial reason.

Payment posting:

Payment posting not only involves of posting payments but also consists of posting adjustments, forwarding balance to secondary or tertiary payer, billing patients and posting denials.

Claim paid:

Once the claim has been processed and paid, the payment posting team post the payment & adjustment to patient account and the balance(copay/coins/deductible) either forwarded to secondary/tertiary payer respectively or billed to patient.

Claim Denied:

Recognizing denials and posting denials is very important in resolving the denial and also to prevent future claims getting denied for the same reason.

Denial Management:

It is the process of examining and resolving the denied claims, and getting reimbursed from the insurance company.

Follow up: The final step in the medical billing process AR Analyst/Callers must resolve and follow up with insurance company for the claims denied and make sure claims are paid.

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