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medical billing process

The medical billing process is a core step in a patient-doctor relationship. Medical billing services ensure payments for all services rendered go through. It also helps keep track of your accounts receivables and accounts payable. Successful physicians’ or medical biller earnings are appropriately based on the collected revenue. However, this is possible if the medical billing process is flawless.

Key Steps to Medical Billing Process

While the medical billing process appears overly complicated, it is a set of easy steps that, when followed with precision, make medical billing easier. These steps include:

1. Demographic Entries and Verification

The most crucial step is to retrieve patient information; these details include the name, residence, gender, and contact information of the patient. Plus insurance relating information is also essential and includes:

  • Insurance policy
  • Policy number or identification
  • Name of insurance provider/company

In this step, you will be asked to enter the patient’s insurance card details while entering a patient’s demographic information. Here you can also use other documentation that confirms their identity, such as a driver’s license or a passport. The demographic area and the insurance information must be carefully recorded and updated regularly if the patient visits the medical practice frequently.  

This information is the foundation of a medical claim for rewarding healthcare practitioners. The errors or discrepancies between entered data and your company’s data can be addressed swiftly. When it is time to pay these bills, the errors will not affect your medical billing cycle.

2. Claim Submissions

Submission of clean claims is the first and most important step for a successful medical billing process. Successful claims submissions translate to boosted revenue for your medical practice, with a faster turnaround time for your patients. The entire claims submission process needs to be done timely, and accurately so your patients don’t end up paying out of their pockets or pay any penalties when there is nothing wrong with your patient’s insurance coverage.

All this means doing the process carefully from start to finish by following industry guidelines and using complaint templates. Also, keeping track of all documentation and being able to elaborate on why each element is vital while presenting any related questions regarding this part.

3. Charge Entry

This step involves inputting all costs for the services rendered to the patients. Also, charge entries contain an appropriate connection of the medical codes to treatments and services performed during a patient’s visit. All charges for the services rendered are entered into a sheet before a collection is sent out to an insurance company. The medical records of patients are meticulously monitored and updated appropriately. These input charges will be submitted to the medical billing company for payment via insurance. All of the charge input sheets need to be error free or reflected during a claim. Accurate entries necessitate quicker revenue claims and payment postings.

4. Payment Processing

Payment processing is the procedure of receiving payment from patients. It can be done in two ways, offline or online—third parties who charge a fee and accept credit card payments over the web process online payments.

Multiple offline payment options include cashier’s checks or wire transfers. One might also have manual payment processing options if one prefers to use something different than the automated methods. The manual payments also let you set specific dates when the bills can be made due; this ensures that bills are never in arrears again.

5. Denial Management

Denial is a common occurrence and a problem in medical billing. When faced with denials, the first step is to understand why denials happen and how. Plus, what can be done to enhance your chances of getting paid? It is essential to know that each claim comes with a risk factor, but there are multiple ways to minimize this risk. If an insurance organization moves to deny your claims, it usually means of the below-mentioned things:

  • Your patient doesn’t meet the basic eligibility criteria or requirements, be it income or age.
  • Your patients’ policy doesn’t cover what you submitted as a part of the claim form, for instance, the prescription drugs.

6. Account Receivables Management

The primary purpose of the successful receivables management process is to collect money from your patients for services you have given them as a medical practitioner or a medical practice. Below are the critical steps for the receivables management process including:

  • Patient Billing
  • Collections
  • Follow-Up and Referrals

7. Correct Medical Coding

The medical scripts are made to make their way to medical coders, and these coders convert your treatments, diagnosis, and other related data into standardized ICD-10 and CPT codes. The insurers can then use these codes to determine whether or not they shall reimburse the patients based on their health plans.  

These codes also appear on medical claims along with the charges and patients’ demographic information. The procedure codes also describe a patient’s treatment strategy. To offer more detailed information about the process or the service, use CPT and HCPCS code modifiers. Only armed with relevant codes and modifiers can the insurance payer make up a proper evaluation.

8. Tracking Claim Adjudication

Adjudication is a process via which payers elevate compliant and valid medical claims and the amount of reimbursement to the providers. These claims can move to be approved, rejected, or refused during the process. The insurers reimburse providers for acceptable claims under the agreements. The rejected claims contain errors to be rectified before the claim can be resubmitted. A refused claim is one where the payer declines to pay.

9. Patient Statements

Patient statements are documents that carry all of the information in pertinence to a patient’s bill. This is sent to the patient after their medical bills have been processed and treated, so they can easily download and review it. This statement includes payment options, deductibles, copays, and more.

If some non-zero debt occurs from the submission of a claim for a patient without secondary insurance, one must offer them a statement describing their charges. One must also send out a benefits explanation to elaborate on what the patient gets and does not get via their insurance plans. This is how patients can understand why they owe you money despite having insurance.

10. Follow Up

The last step for improving efficiency in the medical billing process is to ensure that the bills get paid. Medical billers are responsible for mailing out the precise medical bills, that too on time, and then keep following up with the patients whose bills get past their due dates.

The data is saved inside a patient’s file after it is paid. Again, medical billers are responsible for ensuring that the providers are reimbursed appropriately in case of late or half payment. This might entail approaching the patients directly, sending out follow-up bills, or in the worst-case scenario, getting hold of the services of a collections agency.

11. Medical Billing Analytics, Dashboards, and Reports

In addition to the primary data you need to offer your clients, multiple other analytics, reports, and dashboards can be helpful in a medical billing lifecycle. These include but are not limited to the following:

     a. Medical Bill Status

This status report shows the portion of a patient’s bill that the insurance companies or Medicare has paid. It also elaborates an estimate of what percentage of the remaining amount shall be covered by insurance coverage in every case.

     b. Patient Satisfaction 

The patient satisfaction dashboard offers your patients an overview of their customer experience with your medical practice, including satisfaction factors, communication, treatment options, scheduling, and more at the time of their visit. The lower half of this dashboard can be used to seek to advise on what could be made better for future patients.

Final words

The medical billing process can only become successful if it is flawless from the get-go. Your practice must perform all these processes meticulously, with proper documentation and customer care.

Does it sound too overwhelming? Let the Physicians Revenue Group help you with medical billing services. At PRG, we take the lion’s share of the legalities while letting you work on the patients exactly how it should be. Not only do our expert medical billers keep the entire revenue cycle management of your practice straightforward, but our medical auditing services also offer you multiple ways in which you can grow your revenue to new heights.

Frequently Asked Questions

The most common reason for denied claims is incorrect information. Be it by accident or intentionally, coding and billing errors are the most common reasons for claims denials due to incomplete, missing, or incorrect information.

Your billers can forward an appeal letter to the insurance provider stating why you believe the claim denial is wrong, thus, requesting the insurance company to reverse the denial.

It is a strategic process that aims to resolve and unmask problems that lead to claim denials.