Mastering the basics of Medical Billing Process

A recent study in 2022 has revealed that a total sum of 110,000 claims are denied due to prior authorization in healthcare facilities. These denials can be avoided if the billing process is carried out by a reliable Healthcare Revenue Cycle Management or medical billing company. In this guide, We will be elaborating the entire billing process in detail. By the end of this journey, you will be able to understand the process of the medical billing.

What is the Medical Billing Process?

The medical billing process, also known as the billing cycle, starts with the registration of a patient and ends with reimbursement received by the provider. There are three key players: the patient, the provider, and the insurance company. The whole process revolves around these participants. Every step should be completed correctly so that the provider can receive payment on time. The process includes:

Check whether the patient is insured or not
Correct coding for a specific diagnosis
Claims submitted to the insurance company for reimbursement

Step-by-Step Guide to Medical Billing Process

Dealing with medical bills can be frustrating. It is time-consuming and stressful for medical billing companies. Following are the medical billing steps that you need to understand to speed up billing activities.

Step 1 Registration of Patients Information

The first step in the medical billing process is the registration of the patient’s data when he calls to make an appointment. This can be done in two different ways: manually and electronically.

The front desk staff needs to take the following information:

Name
Home Address
Phone number
Date of Birth
Medical History
Insurance Provider Name

The reasons for collecting this information are obvious. It helps to check the eligibility of the patient for the specific insurance program. If the data is accurate and precise, there are better chances that the insurance company will approve the claims.

Step 2 Verification of Insurance Coverage

The second step in the medical billing process is to check the insurance coverage of a patient. This step is quite simple and can be done by two different methods:

Direct call to the Insurance Company
Check Online

Insurance companies are just a call away. You can call to check the patient’s insurance card against the Medicare card. If the information, such as name, address, and date of birth, is not the same, it can be a cause of claim denial. You can also check the eligibility of patients through the online website. For this, you only need internet connectivity.

Verification Checklist

The start and end dates of a policy
Copay specifications
Coverage limitations
Data regarding patient’s deductibles
Documentation requirements

Step 3 Making Superbills

After the patient leaves the facility, the next step is to compile all the information on one document. An in-depth invoice summarizing the services given to patients is what we call superbills. It consists of the patient’s demographics, insurance, and medical information.

If a person is a regular client, he must update or verify the information already present on his record. The provider also needs to ask for official identification, such as a license or passport.

Superbills compiles the information, such as:

Patient’s demographics
Patient’s medical history
Procedures and services
About the provider and his practice’s policies
Procedural coding

Step 4 Claim Generation and Submission

Biller uses the superbills to generate medical claims, which are then submitted to the insurance company. Be careful while generating the claims, as minor errors in coding and formatting can result in denials or rejections.

Claims must contain information such as procedural codes (CPT or HCPCS codes). They should strictly follow the Health Insurance Portability and Accountability Act (HIPAA). Claims can be submitted directly or through a clearing house. Clearing houses act as a third party company which helps the insurance companies and healthcare providers to communicate.

Step 5 Monitoring of Claim Adjudication

The process by which payers decide whether or not a medical claim is valid and how much reimbursement will be given to the provider is called adjudication. The claims can be accepted, denied, or rejected at this stage.

If Accepted:

It is an ideal situation. If a claim is accepted, it will be processed further. The amount the insurance company will pay depends on the specific insurance plans.

If Denied:

Denied claims are those that are filed properly but do not fulfill the criteria for payment. There can be a reason that a biller has claimed a service that is not covered by that insurance company.

If Rejected:

Rejected claims are those that are not properly filed. There is some sort of error or mistake in the claim. Most of the rejected claims are never resubmitted. Thus, a huge amount of revenue is lost.

Step 6 Patient Statement

When the insurance company pays their part of the reimbursement, the remaining balance is transferred to the patient as a separate statement. If everything goes well, the patient will pay you for your time and efforts. The patient statement includes:

How much the patient has paid
How much the insurance company paid
How much the patient still has to pay.

Step 7 Follow Up

Follow-up is the last and most important step in the billing process. You need to stay in touch until you get paid. Once the patient has received the payment statement,the biller should do anything possible to prevent any issues and facilitate the payment being received by the patient.

Conclusion

In conclusion, this journey has uncovered the secrets to a successful medical billing process. Through this guide, we have come to understand that the billing process is not just paperwork but an essential component which ensures that providers are given appropriate compensation for their services.

Partner with Medheave

If your billing process is not properly managed, this can lead to delays in payment and impact cash flow and revenue. Find a reliable partner who can handle all your billing and coding processes. Medheave’s highly qualified and trustworthy team can manage all your medical billing and coding processes, allowing you to focus on your patient’s treatment.