All You Need To Know About The Medical Billing Process

Priya Naha

Senior Writer

medical billing process

Did you know, healthcare providers fill out an average of 20,000 forms yearly?

Hospitals face a lot of hassles when it comes to settling payments or with regards to insurance. Patients are free of their responsibility when they submit insurance details at the hospital’s front desk. However, the hospital or healthcare facility does not receive the final payment till the insurance agency settles the claim.

It is very important to have a thorough understanding of the medical billing service if you need to get quicker payments. Many facilities are investing in medical billing software or outsourcing their services to focus more on serving patients. Let us try and understand how the medical billing process works. 

Steps in Medical Billing Process

steps in medical billing

1. Patient Registration

The first step in the medical billing process is to collect data which includes insurance verification in a detailed format. This is needed only for a new patient as data of older patients is already stored in the system. Doing this gives medical billers a chance to verify the details before claim submission.

Looking for Medical Billing Software Software? Check out SoftwareSuggest’s list of the best medical billing software solutions.

2. Insurance Verification

Once data is collected, the medical billing team verifies the patient’s data. The team first focuses on policy benefits and verifies the eligibility. This gives them a clear idea of the insurance claim can be obtained for the services rendered or not. 

Once they get an idea, they check on patient responsibilities such as co-pay, deductible out of the packet, and if the patient has accumulated the expenses. 

For certain services, prior authorization is needed from the insurance company. If the said insurance company gives a heads up, the service is ready to be provided. The hospital staff can verify data using medical billing software to speed up the work.

Also Read: Best Software for Doctors to Manage their Practice

3. Record Patient Details

When a patient consults a healthcare provider, details of the condition and service rendered are recorded either by audio or video. These may be recorded in front of the patient or after the encounter. 

This gives a clear idea of the conditions and medications that the doctor has prescribed. Subsequently, the record is forwarded to process medical billing and claim revenue which is maintained in the healthcare CRM system.

4. Medical Transcription

The recorded audio/video is then transferred into a medical script. The script contains the complete condition of the health record. This process of transferring voice/video medical reports by healthcare providers is known as medical transcription. But, why is it important?

Maintaining a formatted and edited file is essential. It must be ensured that the transcription does not hold any false or wrong data, as it might put the patient’s health at risk. 

5. Medical Coding

Once the medical file is checked thoroughly, the transcripted information is converted into medical codes. Reading and analyzing the patient’s complete medical history can be a cumbersome process, so the info is scripted into codes. 

Only licensed practitioners are involved in the process. These professionals have extensive experience in medical coding and rely on DX (condition of the patient) and CPT( service rendered to the patient) to transcript patient records into medical codes.

6. Expense/Charge Entry

After converting the data into medical codes, the charges for the services are entered in the main patient record. This is done before making claims from the insurance company. 

The charges entered are claimed by the medical billing company with insurance for reimbursement. For easy revenue claims, it must be assured that there are no erroneous entries.

7. Charge Transmission

Transmitting the claims with accurate coding through EDI (Electronic Data Interchange) to the insurance company is called charge transmission. Only clean claims without errors are sent through EDI.

The errors can be of three types: 

  • Scrubbing:  All mandatory fields need to be filled, else the software would reject the claim. 
  • EDI rejection: There should be no invalid information in the patient’s record. Such data will cause a claim rejection by EDI. 
  • Payer rejections:  Rejection in claims occur according to the insurance guidelines and payer details.

Denials or payments are made only after these three levels.

8. AR Calling

The role of an accounts receivable (AR) caller is very important in any medical billing process. They concentrate on lower denials and increase payment flow. 

Their primary focus is to ensure payment posting for the services is made correctly by healthcare providers. They are responsible for sharing accurate details of patients and rectifying if any errors are found.

9. Denial Management

Another important step in the medical billing process is denial management. It facilitates profitable revenue growth and reduces rejections from insurance companies. 

The process involves addressing denied claims and maintaining constant follow-ups. The denial management team needs to take appropriate actions to decrease denials and increase the frequency of payments. So, how can this be achieved?

Each denied claim should be analyzed and researched, and the whole process should be accelerated to ensure maximum reimbursements.

10. Payment Posting

The final step in the medical billing process is to post payments to the patients. The posting team records denials and payments. They are also responsible for sending explanations of benefits, correspondence, and electronic remittance advice to patients. Moreover, the team needs to match bulk payment receivables and tally them with the cheque amount. 

5 Benefits of Using Medical Billing Services

Now that you have understood how the medical billing process works, let us understand the benefits of using a medical billing service.

1. Expert Service 

In many facilities, the task of billing and filing claims is a full-time job, expected to be completed in a few hours. Due to this, errors can creep in. So, trusting billing responsibilities to a specialized service will help it get the attention it deserves. Moreover, it will reduce your time constraints and the possibility that claims will be filed incorrectly.

2. Improved Efficiency

Hiring a medical billing service means the rejected claims or collections that once caused you headaches are now the responsibility of your vendor. This allows you to focus on finishing your work and save on labor hours.

3. Bill At The Highest Rate

In addition to reducing your workplace labor spent on billing and claims, your medical billing service should also help you earn extra money. Now, how is this possible? Well, you can take the help of a medical billing service or invest in the medical billing software. 

Both of them will let you recognize revenue opportunities that you may miss when filing manual claims. This means if you choose to invest in a medical billing service, it has the potential to pay for itself in no time.

4. Easy To Use

Optimizing your medical billing service should not require any technical expertise. Instead, you must expect your system to be implemented in less than a day. Moreover, if your team has any issues with the software you can expect your vendor to ask those questions for you.

5. No Capital Expense 

Your medical billing service should be a web-based solution. This will allow you to enjoy its advantages and not worry about the space or finances required to run the system. 

Moreover, partnering with medical billing services puts the onus on your vendor to make sure that your claims are settled in the best possible manner.  

Some vendors even provide you with a technology solution that integrates with your facility’s existing system. This helps you merge your medical records, claims, medical practice management tools, and billing systems into one suite. 

This was how a medical billing process works and why outsourcing it can work best for you. 

Did we miss out on any aspect? Let us know in the comments below!

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