Medical billing is an integral part of the modern healthcare industry. Unfortunately, loopholes in paperwork and small mistakes throughout the process can impact a practice’s revenue. While, like coding, the billing process may seem multi-faceted and complicated, it’s actually comprised of just eight simple steps. The first portion of this article will review the sub-processes of medical billing from start to finish; the latter half will consist of tips to improve your billing workflow and ensure all parties are maximizing their efficiency, accuracy, and returns. Keep in mind while reading that there is a difference between “front-of-house” and “back-of-house” duties in medical billing.
This is the first and most obvious step of medical billing. A patient calling to set up an appointment is essentially preregistering for their visit. Patients that the provider has had in the past will already have information on file and need only to state their reason for the visit. New patients will have to provide adequate personal and insurance information to prove that they are eligible to receive the provider’s services.
Confirm Financial Responsibility
After the biller has the necessary patient information, they must see who will be paying for the visit. This is determined by evaluating the patient’s insurance plan; insurance coverage fluctuates based on the provider, customer, and specific plan, so it’s important to verify what exactly will be covered by insurance. If the insurance plan will not cover any of the service or procedure, the biller is required to inform the patient that they will be paying for the bill in its entirety.
These procedures are pretty clear front-of-house obligations. Upon arrival, patients will be asked to complete forms or verify their information and provide official ID. At checkout, the patient’s medical report is sent to the medical order, where it is translated into medical code, or the “superbill”. The superbill will have all relevant information vital to the creation of the claim, and it is transferred to the medical biller. Moreover, depending on the preference of the provider, copayments are collected either at check in or check out.
Prepare Claims and Check Compliance
Next, the medical biller will take the superbill and put it either in paper claim form or in the proper practice management/billing software. They will also send the payer the cost they are expected to pay. Once the medical claim is created by the biller, the biller is responsible for ensuring that the claim meets all standards of compliance.
Entities covered by HIPAA are required to send their claims electronically; overall, this is beneficial to the biller, since billing electronically saves time, effort, and money, and it mitigates mistakes. Billers may send claims directly to the payer, but in most cases, claims will go through a clearinghouse: this is an entity that helps to reformat claims to the specific forms required by different payers.
Adjudication occurs when a payer evaluates a medical claim to decide whether it’s valid/ compliant, as well as how much of the claim they will reimburse the provider for. Here is where claims become accepted, rejected, or denied. After adjudication, the payer sends a report back to the biller with information on how much they are paying, why they are paying it, and why some things aren’t being covered. The biller’s job is to ensure that all of the procedures of the original claim are discussed in the report, verify that the codes on the report match those of the claim, and check to make sure all fees are accurate in accordance to the payer/provider contract.
Generate Patient Statement
After receiving and checking the report, a biller will make the statement for the patient, which will show the patient how much the payer paid and how much is left. The statement may also include an Explanation of Benefits (EOB) to help patients understand why some procedures are covered and some aren’t.
Follow-up and Handle Collections
Lastly, the biller needs to be sure that the bill gets paid. It’s the biller’s responsibility to ensure timely and complete payment and that the provider is reimbursed for his or her services. In some cases, a biller may need to contact the patient, send follow-up bills, or work with a collection agency.
Medical billing can be a complicated process; ensuring that the process is consistent and streamlined can help ensure that no mistakes are made and all of the vital parts of the process have been completed. Improving your billing process is going to require end-to-end analyzation, consistent attention, and collaboration. Check out part 2 of our article to learn the leading techniques and strategies for improving your billing process.