“MEDICAL BILLING PROCESS: AN OVERVIEW”

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What is medical billing?

When a hospital provides the patient with its services, they charge an amount of money in return. The hospital authority prepares a sheet which includes the rendered services and the amount of money against it. These types of sheets are referred as bills.

What is medical billing process?

There are some certain processes through which the patient needs to pay the bill to the hospital. These processes have made the billing system a lot more organized and hassle-free. The billing process goes through several steps of verification and confirmation regarding the medical condition, insurance policy, severity of the patient’s health issues, etc. before the final step.

How do these processes work?

• Medical claims are forwarded to the billing team by the hospital via courier or scanned documents, accompanied by patient health records, charge sheets, health coverage verification data, a copy of the insurance card, and any other patient information.
• When it comes to insurance payments, healthcare providers and hospitals face numerous challenges. They need to verify whether the insurance claimed by the patient is authenticated or not. They have to make sure the payment is done without any due as well as the patient must not feel like they are being dragged in a lengthy procedure just to pay their bills to the hospital.
• To make the process less chaotic, there are some agencies that deal with all the procedures and help both the hospital and the patient. The payments are considered to be settled once patients submit their insurance information at the hospital’s front desk. However, until the insurance company settles the claim, the hospital or healthcare facility does not receive the final payment.
• The insurance company sends an agent for the verification process. The agent checks the patient and the medical reports and gives the report to the insurance company. The report submitted by the agent is considered to be an authentication. After the verification by the agent, the company releases the bill to the hospital authority. Some hospitals work in a tie-up with insurance companies as well.
• Hospitals can relax and sit back?during the various stages of the process, while the medical billing services do the procedures.

Some clearly defined steps are followed in order to simplify the medical billing process and minimize the daily hassles encountered by hospitals and other healthcare facilities:

Closed System:

A closed medical billing system tracks the health records of a patient digitally and focuses on the practice session. In this case, electronic medical records (EMRs) are indeed the most preferred digital tools. EMRs contain complete patient information, such as the diagnosis the patient went through and all the corresponding treatment plans for the patient etc. They are still not intended for use outside of procedures but could be accessed within the practice for a better assistance by connecting several EMRs. Nevertheless, they are merely some electronic medical paper charts from the earlier days.

Open System:

Unlike the closed system, this open medical billing system demonstrates the importance of a more coordinated design. The patient’s complete health information is transferred to more than one practice through the use of Electronic Health Records (EHRs). This category of billing system allows service providers, patients, relevant parties, health coverage payers, medical billing teams, and sometimes even third-party contractors and numerous healthcare organizations to conveniently obtain data. When accessed by multiple healthcare professionals, EHRs contain a lot of information than that of an EMR and allow for editing.

Isolated System:

This medical billing system is meticulously maintained by the patient using Patient Health Records (PHRs). The patient maintains these records personally by directly recording the details at their convenient times. There are some specific?software tools available that can assist patients with this entire task to perform smoothly.

To keep the billing processes more convenient and systematic there are some steps that are to be followed by the parties during the whole procedure. Some of the steps in the process of Medical billing are as follows:

1. Registration of the patient
2. Verification of insurance
3. The rendezvous
4. Medical transcription
5. The medical coding
6. Charge entry
7. Charge transmission
8. AR calling
9. Management of rejections
10. Payment posting.

Registration of the patient

• Data or information, including insurance verification, is detailed in a template to generate a claim for healthcare services rendered.
• In order to support flawless billing, the RCM company maintains a firm grip on the patient’s record.
• The method described above is only applicable to the new appointment. The information from previous appointments will already be saved.
• It allows medical billers to double-check the information provided before submitting a claim.

Verification of insurance team

• The medical billing team strictly verifies the patient’s insurance from beginning to end.
• Authorization and policy benefits have all been highly emphasized.
• It clearly states whether or not an insurance payout can be achieved for the service offered.
• It examines the patient’s commitments, such as co-pay, deductible, and out-of-pocket expenditures, to see if the patient has managed to accumulate them.
• Certain services require prior approval from the insurance company; otherwise, the facility is ready to be made available.
• To expedite the work, the staff utilizes a software program to verify the personal health information.

The rendezvous

• When a patient visits a healthcare professional, the information of the condition of the patient and the treatment provided are documented, either in?audio or in?video format.
• These details might be documented either during the interaction with the patient or shortly after the interaction.
• It clarifies the ailment and prescriptions provided by the healthcare professional.
• They send the record to the RCM firm, which handles medical billing and claims revenue.

Medical Transcription

• A medical script is generated from taped audio or video footage. The script provides the whole state of the medical record.
• Medical transcription refers to the act of transcribing voice-recorded or video-recorded medical evidence by healthcare providers.
• It is critical to keep a formatted and altered file. Ensure that the transcription contains no misleading or incorrect information, as this could jeopardise the health?condition of the patient.

The medical?Coding

• For a simple and time-saving method, the transcripted information is translated into medical codes.
• Medical coding is the process of converting a patient’s condition, medical treatments, and medical prescriptions into medical codes.
• Reading the patient’s comprehensive medical history takes more time. As a result, it’s written into codes.
• Medical coding is only done by the medical staff. They should be knowledgeable and competent in certain areas of medical coding.
• Coders rely on DX (patient condition) and CPT (service delivered to the patient) to convert the medical record into medical code.

Charge entry

• Before claiming from the insurance company, charges for services given are clearly noted in the sheet.
• Medical records of the?patients are carefully checked and appropriately invoiced.
• The bills input will be submitted to the medical billing agency for payment through insurance.
• Charge input sheets must be error-free otherwise they will be reflected during a claim.
• Accurate input is required for quick revenue claims and payment posting.

Charge Transmission

• Charge transmission refers to the process of transmitting claims with appropriate coding to the insurance company using EDI (Electronic Data Interchange).
• Only valid claims with no mistakes will be sent via EDI.
• Transmission errors are categorized into three types:
• Scrubbing- All mandatory fields must be filled out appropriately. Otherwise, the claim would be denied by the software.
• EDI rejection- Improper information in the patient’s record will result in EDI claim rejection.
• Payer rejections- Claims are rejected based on insurance criteria and payer data.
• Only when these three steps are completed are denials or payments executed.
• Medical billing claims are transmitted in a safe and encrypted manner.

AR Calling

• In Revenue Cycle Management, the AR caller focuses on lowering rejections and increasing payment flow.
• Their prompt follow-up with the insurance company boosts payment receivable.
• The primary goal of the AR caller is to assure payment posting for healthcare professionals’ services.
• They are responsible for communicating accurate patient facts or information and correcting any inaccuracies that are discovered.

Management of rejection

• Denial management is a critical component of Revenue Cycle Management.
• It encourages lucrative revenue development by lowering insurance company denials.
• Addressing rejected claims on a variety of topics and maintaining consistent follow-up.
• Taking the necessary steps to reduce rejections and maximize revenue payments.
• Determine the causes of denials and take steps to lessen the likelihood of future denials.
• The rejection management team analyses and researches each denied claim to determine the best line of action.
• Payments for refused claims should be made as soon as possible.
• To guarantee maximum reimbursements, priorities refused claims based on payer, amount, and other factors.

Payment Posting

• The payment posting team’s role is to guarantee that payments are posted to patients on a regular basis without being denied.
• EOBs (Explanation of benefits), correspondence, and ERAs (Electronic remittance advice) generated from insurance companies will be uploaded to the patient claims that are affected.
• The posting team captures rejections and payments using EOB or communication receivables from insurance carriers.
• It is critical for the posting team to completely match the bulk transaction receivables with the cheque amount.
• The patient and insurance revenues will be estimated using the payment deposited to the service accounts.

These methods take billing process to the next level of Revenue Cycle Management by ensuring consistent revenue increase and access to a substantial range of medical claims?without any mistakes and fewer rejections.