Evaluating Medical Billing Processes

What is Medical Billing?

Medical billing is the translation of healthcare records into a billing claim. A professional medical biller or coder is responsible for all medical billing services. This usually includes following claims to ensure timely reimbursement for services provided by a healthcare facility.

A career in medical billing can be challenging yet rewarding for detail-oriented individuals looking for a somewhat flexible, sustainable profession. While you can complete a course in medical billing in less than a year, many people prefer to obtain at least a two year Associates degree in the field. Medical billing training is often intensive but the occupational knowledge obtained can help you gain a positive foothold in a high demand vocation.

In this article, we will learn more about the medical billing process by breaking it down into ten steps that are easy to understand.

1. Registration

One aspect of medical billing training is instruction on how to properly document a patient’s information. One can only imagine the confusion that could result if even one key element, like age, race or the spelling of a name was wrong. For this reason, it pays to double check the provided information. This is generally personal info such as contacts, current insurance card, and medical history or reports.

2. Insurance verification

The healthcare field can only continue to function if the professionals and institutions within it are paid fully.  Consequently, bills have to be invoiced and resolved in a timely fashion, making the proper acquisition of insurance information imperative. Such info is often submitted by the patient to be verified so that the services covered by the insurance company can be determined.  Coverage data is often obtained following a call or fax to the insurance company. If the insurance provider won’t cover required medical costs, the biller makes the patient aware that they will have to pay the entire bill.

3. Patient check-in and check out

For the convenience of both the patient and providers, people coming in for treatment have to fill out forms that give adequate information regarding current health problems. This aspect is part of the registration process previously mentioned. If it isn’t their first time at the doctor’s office or facility, the patient is asked to provide a driver’s license or passport and a valid insurance card to verify identity.

If and when the information checks out, the medical records are sent by the doctor to the medical coder.

4. Coding

The medical coder analyzes and translates all inputted information, like patient’s diseases, symptoms, and medical procedures in the medical report into accurate medical codes. Now, the coder biller may receive this information in a variety of ways. One is via audio tape, where a specific type of biller, called a transcriptionist, will transform the data into word documentation. The other is via medical forms, which goes straight to the biller to be coded and filed. Accuracy is key here, which is why intensive study is needed for the position.

5. Checking code compliance

Here, medical codes are cross checked to ensure no error occurred when entering them. Coders will also look out for the potential of fraud or abuse, which is often times perpetrated by healthcare workers themselves. As a result, many billers and coders have to be more than a little aware of what the basic guidelines of compliance are.

6. Preparing and transmitting claims

Another aspect where training becomes super important is in the area of claims transmission. At this juncture, the medical coder prepares a superbill, i.e.,  a medical document that contains the name of the patient, physician, procedures performed, code for diagnosis, and other important medical information. The medical coder then transfers the superbill to the medical biller. The biller puts the superbill either in a paper claim form or billing software. The super bill then awaits perusal from an auditor.

7. Auditing a claim

A billing auditor checks the document for errors and fixes any and all identified mistakes. While this process can include innocuous issues like typos, it may also look out for malpractice concerns like irregular billing or over inflated pricing. Essentially, the auditing process becomes a kind of a double check after the compliance assessment.

8. Claim submission

Once checked, rechecked and triple checked, the medical biller can either send the claims to the insurance companies directly or via a clearinghouse. Once it leaves this stage  the superbill becomes the property of the insurance company, who will assess it for claim viability.

9. Denial management

While many claims are approved and processed speedily, others may be delayed or rejected. Delays and rejections often occur for one or two reasons. The payer carefully reviews all the received documents to assess the quality of the claim. If there are errors or missing information, the payer sends the document back to the medical biller for correction. The payer can also fail to make the payment if the claim doesn’t comply with what the patient and the company agreed upon.

10. Reimbursement

The payment made by the insurance payer is received. The biller verifies it is the right amount and then updates the patient’s account. If the amount received isn’t correct, the biller contacts the payer. If the payer denies payment, the medical biller contacts the patient to inform him he is required to pay the remaining balance. Insurance companies don’t pay for services not included in their insurance policies.

In any case, most patients are aware of what they do or do not have access to via their insurance, so by and large, claims are readily handled and resolved.  When a conflict does arise, patients may or may not have recourse in this regard. No matter the outcome, the medical biller is there to streamline a process that assists both patient and doctor in their ongoing pursuit of wellness.