The medical billing process

The medical billing process is used by healthcare providers and insurance companies to submit and follow up on medical services in order to receive payment. There are ten steps to the medical billing process. These steps are made up of three categories: The visit, the claim, and post claim. Steps one through four occur during the first visit to the healthcare provider. Step on is pre-registering the patient. A schedule or an appointment update needs to be made to pre-register the patient. Insurance information and demographics on patient must be collected during this visit.

A medical reason must be provided for the visit. Determining the patient’s financial responsibility is the second step. To be eligible for insurance coverage doctor’s office standards must be met by the insurance provider. Patients are responsible to pay whatever percent of the bill that the insurance does not cover. If the patient does not have insurance, the patient is responsible to pay the whole bill. Checking the patient in is the third step. If the patient is new all insurance and medical information is collected.

Returning patients have to verify and change information if any information is wrong or has changed. Photocopies of Drivers licenses and insurance cards are taken a filed for future use. Patient must fill out medical forms before being seen by the doctor. Co-payments are paid before or after the visit depending on doctor office policy. The Check-out procedure is the fourth step. For billing purposes, all visits, diagnoses, and treatments are documented and coded. Medical insurance specialists use the medical codes for procedures and diagnoses to update patient files and submit claims to the insurance companies.

Category two of the billing process is the claims category. Steps five through seven are included in this category. Reviewing the coding compliance is step five. There are official guidelines that must be followed by medical codes to satisfy insurance company requirements. In order for insurance companies to identify the necessity of medical charges, all medical services must be linked with the medical record. Step six is checking the billing compliance. A specific medical/procedure code is assigned to each charged visit.

Separate fees apply to each charge, but not all are billable. Codes can only be billed according to what the insurance companies’ policies are. Preparing and transmitting claims is the seventh step. Timely and accurate healthcare claims are a must. Information about the patients, visit, procedure, diagnosis, and charges to the insurance company are all in the claim. A schedule is usually set for transmitting claims such as every other day or twice a week. Category three is known as the post claim. The post-claim includes steps eight through ten.

Step eight is monitoring payer adjudication. Adjudication is the process in which insurance companies review medial claims. Adjudication judges whether a claim should be paid or not. The claim may be partially paid, paid in full or not paid at all. The report is sent back with specifics on why they paid for the amount paid. Additional claims are sent out for the remainder of the claim if a patient is covered by more than one insurance company. Generating patient statements is step nine. Payments from insurance companies are applied to individual accounts accordingly.

Payments that are not fully paid are sent to the patient to pay the remaining amount. The bills mailed to the patient are itemized telling them the date and procedure and what has been paid by insurance and the remaining amount they need to pay. The final step is Following up on patient payments and handling collections. Payments are analyzed on a regular basis. If payments are continuously late or stop coming in a collection process will be started. Financial and medical records are filed and retained once all bills are paid. The federal government decides how long medical records must be kept.

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