5 Main Steps in Medical Billing Process

Like medical coding, medical billing might seem large and complicated, but it’s a process that’s comprised of five simple steps. These steps include Registration, the establishment of financial responsibility for the visit, patient billing compliance, preparing and transmitting claims, generating patient statements or bills, and assigning patient payments.

1. Patient Registration

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 they are eligible to receive services from the provider.

2. Financial Responsibilities

Financial responsibility describes who owes what for a particular doctor’s visit. Once the biller has the pertinent info from the patient, that biller can then determine which services are covered under the patient’s #insuranceplan. Insurance coverage differs dramatically between companies, individuals, and plans, so the biller must check each patient’s coverage to assign the bill correctly. Certain insurance plans do not cover certain services or prescription #medications. 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.

3. Superbill Creation

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 an 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 “superbill.” The superbill contains all of the necessary information about the medical services provided. This includes the name of the provider, the name of the #physician, the name of the patient, the procedures performed, the codes for the diagnosis and procedure, and other pertinent medical information. This information is vital in the creation of the claim. Once complete, the superbill is then transferred, typically through a software program, to the medical biller.

4. Claims Generation

The medical biller takes the #superbill from the medical coder and puts it either into a paper claim form or into the proper practice management or billing software. Biller’s will also include the cost of the procedures in the claim. They won’t send the full cost to the payer, but rather the amount they expect the payer to pay, as laid out in the payer’s contract with the patient and the provider. Once the biller has created the medical claim, he or she is responsible for ensuring that the claim meets the standards of compliance, both for coding and format. The accuracy of the coding process is generally left up to the coder, but the biller does review the codes to ensure that the procedures coded are billable. Whether a procedure is billable depends on the patient’s insurance plan and the regulations laid out by the payer. While claims may vary in format, they typically have the same basic information. Each claim contains the patient information (their demographic info and medical history) and the procedures performed (in CPT or HCPCS codes). Each of these procedures is paired with a diagnosis code (an ICD code) that demonstrates the medical necessity. The price for these procedures is listed as well. Claims also have information about the provider, listed via a National Provider Index (NPI) number. Some claims will also include a Place of Service code, which details what type of facility the medical services were performed.

5. Claims Submission

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/complaint 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. A quick word about these terms. An accepted claim is, obviously, one that has been found valid by the payer. Accepted does not necessarily mean that the payer will pay the entirety of the bill. Rather, they will process the claim within the rules of the arrangement they have with their subscriber (the patient). A rejected claim is one in which the payer has found some error. If a claim is missing important patient information, or if there is a miscoded procedure or diagnosis, the claim will be rejected and will be returned to the provider/biller. In the case of rejected claims, the biller may correct the claim and resubmit it. A denied claim is one in which the payer refuses to process payment for the medical services rendered. This may occur when a provider bills for a procedure that is not included in a patient’s insurance coverage. This might include a procedure for a pre-existing condition (if the insurance plan does not cover such a procedure). Once the payer #adjudication is complete, the payer will send a report to the provider/biller, detailing what and how much of the claim they are willing to pay and why. This report will list the procedures the payer will cover and the amount payer has assigned for each procedure. This often differs from the fees listed in the initial claim. The payer usually has a contract with the provider that stipulates the fees and reimbursement rates for several procedures. The report will also provide explanations as to why certain procedures will not be covered by the payer. (If the patient has secondary insurance, the biller takes the amount left over after the #primaryinsurance returns the approved claim and sends it to the patient’s secondary insurance). The biller reviews this report to make sure all procedures listed on the initial claim are accounted for in the report. They will also check to make sure the codes listed on the payer’s report match those of the initial claim. Finally, the biller will check to make sure the fees in the report are accurate about the contract between the payer and the provider.

Follow Up

The final phase of the billing process is ensuring those bills get, well, paid. Billers are in charge of mailing out timely, accurate medical bills, and then following up with patients whose bills are delinquent. Once a bill is paid, that information is stored in the patient’s file. If the patient is delinquent in their payment, or if they do not pay the full amount, it is the responsibility of the biller to ensure that the provider is properly reimbursed for their services. This may involve contacting the patient directly, sending follow-up bills, or, in worst-case scenarios, enlisting a collection agency. Each provider has its own set of guidelines and timelines when it comes to bill payments, notifications, and collections, so you’ll have to refer to the provider’s billing standards before engaging in these activities.

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