Medical Billing Process: A Must Read For Every Healthcare Professional

Medical billing is a sequence of actions carried out by billing specialists to guarantee that medical providers get paid for their services. It may take a few days to finish, or it may take many weeks or months, depending on the conditions. While each medical office’s procedure may vary significantly, below is a rough sketch of a medical billing system.

This article details the process of medical billing. 

Registration of Patients

The initial stage in every medical billing flow chart is patient registration. This is the gathering of a patient’s basic demographic information, such as name, birth date, and purpose for visit. Medical billers gather and verify insurance information, such as the name of the insurance provider and the patient’s policy number. This data is utilized to create a patient file that will be referenced during the invoicing process.

Financial Responsibility

The second stage in the procedure is to establish who is responsible for the visit’s financial costs. This entails reviewing the patient’s insurance information to determine whether treatments and services are covered during the appointment. If there are any procedures or services that are not covered, the patient is informed that they will be liable for the charges.

Creation of Superbill

During check-in, the patient will be asked to fill out paperwork for their file or, if this is a return appointment, to confirm or amend information already on file. Identification, as well as a valid insurance card, will be required, and co-payments will be collected. A medical coder converts medical information from the visit into diagnostic and procedure codes once the patient has checked out. Then, using all of the data obtained thus far, a “superbill” report may be created. It will include information about the provider and clinician, the patient’s demographics and medical history, information about the procedures and services provided, and the diagnostic and procedure codes that apply.

Creating Claims

After then, the medical biller will utilize the superbill to create a medical claim that will be sent to the patient’s insurance carrier. Once the claim is produced, the biller must carefully review it to ensure that it complies with payer and HIPPA compliance criteria, including medical coding and format requirements.

Submission of Claims

The next step is to submit the claim after it has been validated for correctness and compliance. The claim will most likely be sent electronically to a clearinghouse, which is a third-party firm that functions as a mediator between healthcare providers and health insurance. High-volume payers, such as Medicaid, are an exception to this rule, as they will receive claims directly from healthcare providers.

Keeping an eye on the claim adjudication process

Adjudication is the process through which payers assess medical claims to determine if they are genuine and compliant, and if so, how much the provider will get in payment. The claim may be approved, rejected, or refused during this stage. A claim that has been approved will be reimbursed according to the terms of the insurer’s contract with the provider. A claim that has been denied has mistakes that must be fixed before it may be resubmitted. A rejected claim is one that the payer will not pay.

Preparing a Patient Statement

The patient gets invoiced for any unpaid charges after the claim has been processed. A full account of the operations and services done, their prices, the amount covered by insurance, and the amount due from the patient is usually included in the statement.

Follow-up on the Statement

Making ensuring invoices are paid is the final stage in the medical billing process. Medical billers are responsible for following up with delinquent patients and, if required, sending accounts to collection agencies.

Hope this article was helpful!