An overview of Medical Billing Process

The Medical Billing Process is basically divided into the following:

1.  Insurance Verification.

2.  Patient Demographic Entry.

3.  Medical Coding.

4.  Charge Entry.

5.  Claims Submission.

6.  Payment Posting.

7.  A/R (Account Receivable) Followup.

8.  Denial Management.

9.  Reporting.

Insurance Verification

• After an appointment is fixed with a provider, the patient submits the insurance details to the provider’s office.

• The provider’s office checks with the insurance if the patient is active and the services that need to be provided are covered by the patient’s insurance or not.

Patient Demographic Entry

• Demographics consist of the following:

1. Patient Name.
2. Date of Birth.
3. Age.
4. Sex.
5. Address, contact number.
6. Insurance Details.

All the above are entered into the EMR once the patient appointment is fixed and the insurance is verified.

Medical Coding

• Once the provider renders services to the patient, the provider documents all the services, diagnosis, and procedures.  The documentation is done through Medical Transcription or the provider enters directly into the EMR.

• All the documented services, diagnosis, and procedures are coded by a Medical Coder giving an alphanumeric code to each service, procedure and diagnosis.

Charge Entry

• Charge entry is the process of entering all the codes into the billing software.

• Also assigning the value for each code as per the fee schedule.

• Entering the insurance details for the respective patients.

Claims Submission

• Once all the charges are entered into the billing software, these are checked for any errors and transmitted to the respective insurance companies.

• If an insurance company accepts claims electronically, then they are submitted electronically or else paper claims are mailed to their respective addresses.

Payment Posting

• Once all the claims are submitted, we start receiving payments from the insurance companies between 7-30 business days.

• The checks/EFTs will be directly transferred to the provider’s account.

• The insurance company will also post an EOB/EOP (explanation of benefit/payment) giving details of the payment and how much amount has been paid for each claim.

• From the EOB/EOP, we need to post into the billing software the respective claim payments.

• We also receive ERAs directly into the billing software, which can be automatically posted.

A/R (Account Receivable) Followup

• We need to follow up on the claims, for which we have not received a payment or any response from the insurance company.

• Firstly, we check online status in the insurance website if any information on the claim is available.

• Then, we call the insurance company and know the status of the claim and reason for the delayed response.

Denial Management

• For the claims which have been denied by the insurance, we need to evaluate the reason for the denial and make necessary corrections and submit them for reprocessing.  This includes:

1. Calling the insurance for reason for denial.
2. Getting information from the provider if anything is required.
3. Getting the information from the patient, if there is an issue with the patient’s insurance plan.
4. Checking with the coding department for coding issues.
5. Finally, resubmitting the claim or filing an appeal with the necessary documents.

Reporting

• Reporting is a very important feature in the billing process through which the provider will know the status of his practice and the changes that needs to be taken in the practice to improve the revenue of the practice.  Some of the important reports are:

• Monthly reports:

1. Payments report:  Payment received for a month.
2. Charges report:  Volume of claims submitted.
3. A/R balance:  The amount still pending with the insurance.

 There are numerous reports, but depending on the provider’s requirement they will be generated.