Medical billing is a process where the billers submit and also follow up on claims that they send to the insurance companies, so that they can get paid in return for their services that the provider gives. There are ten steps in the medical billing process; those steps are then broken down into three parts, the visit, the claim, and the post-claim. The first four set of steps in the medical billing process, are included in the visit process. The first step in the process is the pre-registration of the patients.
In order to pre-register a patient or update a returning patient the medical biller must schedule and update the patient’s appointments. Pre-registration includes a patients insurance and personal information. If a patient calls in their appointment they can usually provide their basic personal information, as well as provide them with what insurance coverage they use. When a patient comes in to the office or calls for an appointment they are asked what is the reason for the visit, so that they can schedule the appointment as appropriate.
The second step in the visit process is where the biller establishes financial responsibility for the visit. This process is important because it determines whether or not the patient’s insurance coverage is covered by that provider. It also determines what services and benefits are not covered. Once all has been established the patient is then told of any charges that their coverage does not cover and they are told that they are responsible for those charges. If a patient is uninsured they are fully responsible for the entire bill. If the patient’s bill is substantial, they are then given payment options.
The third step in the visit process is when the patient is checked in. This process is where the information for new patients is collected and returning patients are required to look over their records to determine that all information is still up to date. Their records are then looked over to make sure that there are no previous bills due. Once this is done the patient is asked to provide their insurance card and driver’s license to be photo copied for their records. If the patient has a co- payment they are asked for that before moving on with the visit.
The patient may be asked for any further information that they may need to complete their records. The last step in the visit process is known as the check-out procedure. This procedure is where the patient’s medical codes from the visit are recorded. This is where the doctor or health care professional treats the patient and records any diagnosis and procedures that they need to bill the patient for after the visit. In order for the patient to be billed for the procedures the doctor needs to use medical codes. The medical insurance specialist verifies the codes with data into the patient’s medical records.
The next three set of steps are included in the claim process. The fifth step is reviewing coding compliances. Compliance means that the actions satisfy the official requirements. When the diagnosis and procedures are coded in the records they need to be looked over for any errors. The medical services that are documented into the patient’s records should be logically connected in a way that the patient understands what they are being charged for. The sixth step in the claim process is to check billing compliance. Each fee that a patient is charged for after the visit is related to a specific code.
Each code is written on the medical practice’s fee schedule, the fees usually stay the same according to their usual fees. Sometimes there is a separate fee that is associated with the codes, but the codes are not always billable. Whether or not a code can be billed all depends on the payer’s rules, after the rules are set when preparing the claims it results in billing. Some payers will include a particular code for the payment of another code. Medical specialist will also provide their input about what can be billed on heath care claims.
The seventh and last step of the claim process is to prepare and transmit claims. This step is where health care claims are prepared in an accurate and timely manner. Most claims are prepared for a patient and sent electronically. A claim’s purpose is to communicate information such as the patient’s diagnosis, procedure, and charges to the payer. A patient may be able to get reimbursed for the services that are rendered. The practice usually has their schedule for when they transmit their claims, sometimes it is everyday and sometimes it is done on a weekly basis.
The last three steps in the medical billing process are included in the post-claim process. The eighth step in the medical billing process is known as the monitor and payer adjudication. Once the information is sent to the payer it is important for the practice to collect the fees from the insurance and from the patient. The money that is collected is what pays for the practice to run their business. The process known as adjudication is done when the payer reviews the claims. The payer looks over the claim and decides whether it should be paid or not.
It is not always that the payer and the practice’s fee’s match exactly. The ninth step is to generate patient statements. This step is when the payments are to be applied, in some cases the bills are not fully paid and the patient must pay for the balance. The amount that the insurance and the patient pay must add up to the fee. The bills are then mailed to the patient which state the dates and what services the patient was billed for. The bill also states what the insurance and the patient have paid and it includes any balances that may be left over.
The last step in the post-claim process is the follow up payments and handle collections. This is also the last step in the medical billing process. This process is where the practice analyzes any past due bills. If this happens the practice sends the bill to collections. The records are then filed and retained; regulations from the state and federal determine how long documents are to be kept.
Reference: The McGraw-Hill Companies, (2008). Working with Medical Insurance and Billing, p. 17-21. Retrieved July 17, 2010 from University of Phoenix.