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February 26, 2024

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What are the 10 Key steps in the medical billing process?

While your primary focus should be on patient care – but as a healthcare practice owner, you must also take care of the financial side of your business. Consequently, you and your staff must follow the 10 key steps in the medical billing process. The process inside medical billing services begins with a patient visiting your practice. A patient’s visit can be in-person or remotely (think telemedicine, for instance). The said process ends when your practice receives payment.

Importance of Medical Billing Services

The medical billing process comes with multi-faceted communication between:

You and your patients
You and your staff
Your office and health insurers

Maintaining proper communication becomes tricky, especially when starting a new private practice. However, if you take care of all medical billing essentials and keep an error-free billing process, you can:

Cut-down on errors
Streamline medical billing processes
Make timely appeals on denied medical claims
Receive timely reimbursements

But what are the 10 key steps in the medical billing process?

10 Key Steps in the Medical Billing

The essential 10 key medical billing steps are:

1. Patient Registration

Any flow chart showing the medical billing process begins with patient registration. This step collects various details to ensure smoother healthcare financial management. The necessary information includes

Patient’s name
Address
Date of birth
Reason for their visit

Equally important is the collection of insurance-related data, encompassing details like:

Insurance provider’s name
Policy number

Before starting treatment, the front desk personnel schedule an appointment with the doctor. This scheduling is done by involving the collection of vital data from the patient. It’s essential to note that the success of the entire medical billing process centers on the accurate and professional execution of patient registration.

2. Insurance Verification

Moving along the key steps in the medical billing process, we have insurance verification. This stage establishes who holds financial responsibility for the upcoming services – the patient or the insurer. Before any services are given, engaging in thorough verification with the insurance company is essential.
During the insurance verification process, key aspects are checked to determine the financial details:

Firstly, confirming the active status of the patient’s insurance policy.
Secondly, evaluating whether the insurance covers the services to be provided.
Lastly, inspect any potential authorization requirements tied to the patient’s coverage.

Moreover, the patient is duly informed about their responsibility for any services their insurance might not cover. This transparency fosters a clear understanding and sets the stage for a smoother medical billing experience.

3. Superbill Creation

When the patient arrives for their appointment, the medical billing process begins. During check-in, patients complete a form for their records. For returning patients, a review or update of existing information may be required. At this stage, identification and co-payments are also collected, ensuring possession of a working insurance card.
Upon the patient’s departure, which marks the second step in the medical billing journey, the collected medical reports undergo coding. A skilled medical coder takes the information from the visit and translates it into diagnostic and procedure codes. Subsequently, these details are combined to generate a document known as a “superbill” or “encounter report.”
The superbill encompasses key information such as:

Provider and physician details
Patient demographics
Medical history
Services provided
Associated diagnostic and procedure codes

This document streamlines the upcoming key steps in the medical billing process, ensuring accuracy and efficiency.
The two pivotal steps in superbill creation revolve around patient check-in and check-out. It also involves gathering essential information and necessary payments while the next steps transform medical reports into a structured superbill, laying the foundation for a seamless medical billing process.

4. Charge Entry/Claim Generation

Entering charges and generating claims are key steps in the medical billing process. Before submitting a claim to the insurance company, recording the service charges accurately is essential. This involves tracking medical data for patients and ensuring that the correct amounts are assigned to each service.
Once the charges are correctly recorded, the medical biller creates a medical claim. Subsequently, the biller is responsible for carefully reviewing the generated claim. This review is essential to confirm compliance with both payer and HIPAA guidelines. It encompasses analysis of medical billing accuracy and following specified formats.

5. Claims Audit

When claims are transmitted through EDI, they undergo a three-level analysis for approval by insurance. These levels, each with specific responsibilities, ensure the accuracy and compliance of the submitted claims.

Scrubbing

EHR Software verifies the completeness of the claim form.
Identifies specific errors based on set requirements.

Clearing House
The third-party contractor overseeing EDI conducts checks on patient records.

Validate policy active dates, the claimant’s name, and date of birth.
Identifies potential coding issues.

Insurance Rejection

Insurance performs a brief check to validate patient data accuracy.
Ensures the policy is active and identifies any obvious billing errors.

Any errors or mistakes discovered at either of these levels result in claims being returned with a rejection message. This three-tiered audit process ensures the approval and subsequent adjudication of claims, enhancing the efficiency of the medical billing process.

6. Claims Submission

Moving to one of the following key steps in the medical billing process, we focus on claims submission. This stage involves presenting the claim to the patient or their insurer. Usually done electronically for efficiency, only accurate, error-free claims are transmitted via Electronic Data Interchange to streamline reimbursement.
After submission, the adjudication process begins. Here, insurers assess claims for legitimacy and legality, determining the provider’s payment. Claims may be approved for reimbursement or denied based on compliance with the insurance agreement. Accuracy in claims is vital to ensure approval and reimbursement, highlighting the need for accuracy in medical billing.
In essence, claims submission is a bridge, connecting the careful examination to adjudication. This step determines reimbursement success, emphasizing the need for accuracy throughout the medical billing journey.

7. Denial Management

Denial management is integral to healthcare revenue cycle management, which aims to boost total revenue by minimizing insurance denials. This involves:

Reviewing denied claims
Implementing measures to enhance revenue collections
Reduce denials
Identifying reasons for and preventing future denials

Each denied claim undergoes evaluation and research for adequate resolution, ensuring quicker payouts and strategic organization based on payer, amount, and other factors to optimize overall payouts. In essence, denial management is a comprehensive strategy for efficient and revenue-optimized medical billing.

8. Patient Statement Preparation

Among the key steps in medical billing is patient statement preparation, followed by claims processing. This phase includes billing the patient for outstanding fees and typically involves:

A detailed account of the operations and services provided during the healthcare visit.
A clear indication of the prices associated with the services, promoting billing transparency.
Outlining the amount covered by the patient’s insurance, if applicable.
Specifying the patient’s portion of the bill ensures a clear understanding of financial responsibilities.

Patient statement preparation facilitates transparent communication of charges, prices, insurance coverage, and the patient’s financial responsibilities.

9. AR Calling

Next on the key steps in medical billing is AR calling, taking center stage. The caller dedicated to accounts receivable (AR) focuses on two primary objectives:

Reducing rejections
Enhancing the overall payment flow in RCM

Firstly, through prompt follow-ups with insurance providers, the AR caller plays a role in facilitating timely payments. Some conduct these follow-ups monthly, while others opt for a weekly pace. The frequency is often determined by the age of AR days, ensuring a strategic approach to converting due amounts into revenue.
Equally important is the primary goal of the AR caller, which is guaranteeing reimbursement for the treatments by healthcare professionals. To achieve this, they must share accurate patient information and promptly correct any mistakes in the billing process.
Furthermore, AR callers send reminders to patients or their insurance providers to maintain effective communication regarding outstanding payments. This approach helps expedite the key steps in medical billing, ensuring a steady revenue stream.
AR has a key role in the medical billing process and focuses on the following:

Reducing rejections
Improving payment flow
Ensuring reimbursement for healthcare treatments

This involves strategic follow-ups, accurate information sharing, and timely reminders to optimize the AR days and convert due amounts into revenue.

10. Payment Posting

Payment posting is important in the key steps of the medical billing process. When the insurance companies approve claims, they disburse funds through a check or electronic transfer, accompanied by an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). Professionals handling payments record these transactions in the Electronic Health Record (EHR) and accurately account for the received funds. This process ensures transparency and maintains an updated financial record, contributing to the efficiency of the medical billing process.

Conclusion

Following the 10 key steps in the medical billing process is essential for healthcare practices. Summarizing the journey, from patient registration to payment posting, highlights the importance of accuracy and efficiency. Healthcare providers must recognize the significance of error-free billing for sustained success. Embracing medical billing services boosts revenue and ensures a seamless financial management system. Make the smart choice for your practice’s financial health – follow the 10 key steps in medical billing. Your success begins with precise and reliable medical billing services.