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10 Steps Involved in the Medical Billing Process

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Basant Kumar
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One of the biggest problems in a medical practice is gathering information on patient services and insurance parties. Different health insurance providers have slightly different billing methods, which make it difficult to submit claim applications. These variations, along with the subtleties of ICD-10 coding, render the invoicing process error-prone when processing claims manually.

Medical practitioners are continuously pressured to increase service yields and outcomes due to rising costs and falling budgets. Many doctors now understand the financial benefits of medical billing services.

These errors can interfere with the cash flow of the practice due to rejected or delayed claims. In addition, billing irregularities also result in the late recovery of payments during Medicaid and Medicare audits. 

These 10 key steps in the medical billing process can help hospitals and healthcare organizations to avoid mistakes.

  1. Patient Registration

Hospital staff collects essential information (age, sex, address, and phone number) when new patients arrive. Insurance-related details such as policy ID and name of insurance are also kept handy. It allows healthcare practices to maintain accurate records and update the system with the latest details. Incorrect information during the insurance claim could lead to a denial or refusal which can further prolong the payout.

  1. Insurance Verification

Prior to rendering medical services, hospitals verify the policy validity, services covered, and any authorization clause with the insurance company. This helps in assessing whether the payment will be made by the insurance company or the patient. Generally, insurance websites provide details, but the information collected on-call can be used to challenge denied claims later on.

  1. Encounter

The term ‘encounter’ is used for the interactions that take place between the patient and the medical service provider. Here, the doctor examines the patient’s condition and determines a treatment plan. This is a recorded session, either via audio or video. By ensuring that the specifics are correctly obtained and that the session is well documented, claims can be prepared properly.

  1. Medical Transcription

Professionals listen to the recorded session and log information in the diagnostic script. This is then used to compile and update the patient’s health history. It should be done carefully as new records will be used later in subsequent follow-ups. Since the physician relies on certain records to administer treatment, any inaccurate details will jeopardize the medical history of the patient resulting in inaccurate decision-making. Not just that, the record is sometimes used for medical billing purposes. Thus, if there is any erroneous detail, it will also impact the claim.

  1. Medical Coding

According to the standards of the American Medical Association, a team of specialists reads the report prepared from the records and focuses on the pertinent material. These include where the treatment was given, the cause for the appointment, the steps taken by the provider to address the condition, etc. As a mandatory step, this information is then converted into numeric or alphanumeric codes. Additionally, coded information is easier to grasp.

  1. Charge Entry

The cost incurred to deliver the service or the full collectible sum is applied to the payments coded by the coding staff. It is an important measure required to prepare the claim form, which is  sent to the insurance provider. Without the specified value, the reimbursement will not be received. The system is supervised by experts to ensure the accurate value is applied because a mistake will lead to decreased payment on the claim.

  1. Claim Transmission

After making the claim successful by incorporating patient information, provider information, services rendered, etc., the claim is now eligible for reimbursement. Thankfully, with the help of technology, claims are submitted through EDI (Electronic Data Transfer), making claim submissions easier and faster. This process can also be outsourced to medical billing services for hospitals.

  1. Denial management

Insurance providers can only process submitted claims within the agreed time period. When approved, they push the claim through a process called adjudication, where they impose specific criteria that determine the acceptance or rejection of the claim. Agents handling denials prioritize the claim according to the time left for insurance submission and the amount to be recovered to ensure optimum collection of revenue.

  1. Account Receivables

The claims rejected by insurers are managed by the account receivables team. They check why the claim was not charged even though corrective measures were taken. These professionals rely on comprehensive follow-up with insurance agencies who compile, evaluate, and coordinate denial of claims to ensure payment flow. 

  1. Payment Posting

Once the insurer agrees to reimburse the claim, the payout is released either in the form of a paper cheque or electronic fund transfer. Along with this, they also submit an overview known as an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). It is the duty of the personnel managing the payment to post the entries in the EHR transcription and match the payment received.

Conclusion

It is important to understand the steps involved in the medical billing process. However, the necessity and obvious benefits of hiring a medical billing company are evident

Medical billing is a tiresome activity that needs to be done with precision. With the help of medical billing for doctors, hospitals can also obtain useful tips on how to boost service delivery and maximize sales. Outsourcing medical billing also saves the practice’s money and resources that can rather be spent on providing better patient care.

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