31 May The Medical Billing Process
There is a special process that medical insurance specialists follow to ensure the physician and the medical clinic gets reimbursed for the service provided. It is called the medical billing process and the series of steps will lead to the maximum, appropriate, and timely payments for the medical services performed for the patients seen at the practice.
The steps here are part of what a medical billing company will do to ensure payment will go through without problem:
– Record Medical Codes
– Medical Coding Compliance
– Ensure Billing Compliance
– Prepare Correctly before Transmitting Claims
– Monitor Claim
– Generate Statements for Patients
– Follow-Up On Patient Payments And Collections
After it has been established as to what services will be covered under the patient’s plans and the medical necessity of the services, then financial responsibility will be determined. Patient eligibility needs to be known so that the patient knows if he/she needs to pay anything out-of-pocket. Billing rules for any health care plans will have to be known as well. It is essential to know how to bill correct in order to get reimbursement for medical procedures and services. It is important to meet payer conditions for payment such as preauthorization. Then the correct procedures will be followed to meet those conditions.
The check-out procedures entails recording medical codes for the visit of a patient. The diagnoses and procedures done would be in the medical records. For billing for these diagnoses and procedures, they all have to have a medical code of the ICD-10.
Review coding compliance is an important part of the medical billing process as it ensures everything is done to satisfy official requirements. There are official guidelines to follow when codes are selected. Errors need to be corrected when found. The diagnosis and the patient’s medical record to be documented where the payer can understand why there is a medical necessity of any charges related to the diagnosis and procedures. A payer source will have their own rules on how a code can be billed. If these rules are followed, billing compliance results. Medical insurance specialists know about each payer’s guidelines so that they know what can be billed on claims.
An integral aspect of medical billing is the preparation of accurate and timely payment. Electronic claims are very common in the industry today. A claim will essentially communicate information to the payer about the patient’s diagnosis, procedures, and the charges to the payer. It will either be for reimbursement from the payer or to report information to an HMO.
The payer will take the claim and put it through a series of steps to determine if it should be paid. It will either be paid in full, partially paid, or totally denied payment with an explanation in the form of a report.
If a patient has more than one health care plan, the other plans will have claims sent to them based on the amounts still due. The payment amount depends on the contract between the practice and the payer. The medical insurance specialist will compare payments with each claim to see that all procedures also appear as a payment transaction. The specialist will also check to see if any unpaid charges are explained ant that the codes match those on the claim. If any discrepancies are found, than an appeal process can be started. When there is an appeal, the medical insurance specialist needs to follow the state or payer’s rules in order to seek the appropriate reimbursement.
Patient statements will need to be generated if there is any services not covered by a patient’s insurance. After all of the payer payments have been applied and there is still a balance, then the patient will be billed for the remainder. Bills will reflect the dates and services provided, any payments made by payer and patient, and the new balance. The bill will go into collection if it is not paid in the time frame allowed by the practice’s billing policy.