Medical Billing: How Does It Work?

Medical billing for a healthcare facility is a fairly complicated financial process between healthcare providers and patients. 

That’s the reason healthcare providers consider joining hands with the experts that are trained to manage medical finances and patient billing of their practice. 

Learn about Medical Billing 

Medical billing is the process of generating healthcare claims to submit to insurance companies for payment for medical services rendered by providers.

After the translation of healthcare service into a billing claim, the medical biller follows the claim to ensure the organization receives reimbursement for the work the provider performed. 

A knowledgeable & skilled medical biller can optimize revenue performance for the provider’s practice.

How does medical billing work?

Medical billing for patients’ services can be a complicated process. It can be quite challenging to understand exactly how it works. 

When deciding on how you want to handle medical billing for your practice, you can either manage it in-house or outsource it. 

Even if you outsource it, you will likely want to understand the process yourself so you have oversight over how your revenue is being handled by your partner. 

The following are some of the steps in the medical billing process.

• Register patients 

When accepting new patients, the patient must provide their personal information and insurance information. 

The medical biller will save this information to the patient’s medical record. The medical biller must check to assure this new patient’s insurance company will cover the services they are getting from the provider. If you are outsourcing billing, you will create the patient record and send it to the medical billing supplier as and when needed.

• Check insurance plan for financial coverage 

Once the medical biller has the patient’s insurance details, they will look into the specifics of the plan’s financial coverage.

Then, they will decide if the patient’s mentioned service is covered under their plan.

This step is extremely important and must be done correctly, every time a patient visits. Every insurance plan is different. If the insurance company won’t cover the mentioned service, the medical biller should tell the patient right away.  Like that, the patient can conclude whether they need to proceed with it.

• Patient check out & medical coding for visit

After the patient has seen the provider, they will check out with reception at the practice. This is the point at which the patient will pay their copay for the visit– depending on the insurance policy. After reception collects the patient’s dues, they will view the patient’s medical report, which is also known to be a ‘superbill’ to see what procedures were done.

If the practice is using an outsourced service, they will add that day’s medical procedure to the superbill. Then, they will send it to the medical biller through easy-to-use integrated software. The biller will take it from that point and make the insurance claim.

• Prepare insurance claim 

Following this, the medical biller will prepare the insurance claim. They will make the right medical codes and enter them into the billing software, which will show the whole expense of the medical procedure. Then, the biller will play out an analysis of the procedure and insurance policy. This will allow them to sort out how much the insurance provider should pay, depending on the patient’s policy.

 

While sending out the bill to the insurance company, the medical biller must assure the claim is compliant with using correct coding, modifying coding, and formatting. If anything is inaccurate, it’s possible the provider will not get the money they are owed.

• Submit claims 

As of 1996, any providers covered under HIPAA must submit claims electronically, rather than manually. The medical biller will submit the claim to the insurance provider through medical billing software for payment. 

Each insurance company may have its standards and guidelines for submitting claims. The medical biller needs to have a good understanding of the policies and procedures for submitting claims to each provider, to push the claim through successfully.

• Adjudication

In the medical billing process, adjudication is known to be the claim’s evaluation process by the insurance provider. Before paying, the insurance company will analyze the submitted claim and conclude whether or not it is valid and compliant. 

The insurance provider will then consider the claim legitimate or invalid. As needs be, they’ll acknowledge or deny the claim. In the event that the insurance provider acknowledges the claim as valid, they will compute the amount they owe the medical practice, depending on the patient’s policy terms.

Once accepted, the insurance provider will connect with the medical biller with a report outlining the payment terms. The medical biller will then re-analyze this report to make sure of accuracy and compliance with the patient’s policy. If everything looks fine, they will give the insurance company the “green light” to cover their portion of the payment.

• Generate payment 

Once the claim has been processed, the patient is billed for any unpaid charges. The statement typically comprises a detailed list of services provided, their costs, the amount paid by insurance, and the amount due from the patient.

• Follow up 

When a patient pays their end of the bill, the biller is told about the finished installment payment information and stores it in the patient’s records. If patients have outstanding bills, it’s the medical biller’s job to follow up with them to find out the issue.

Unite with Capline Healthcare Management to ease the process

After learning about the medical & dental billing process at length, you’ll likely see that outsourcing medical and dental billing services are what you need to take your practice to the next level, boosting patient satisfaction as well as your bottom line.

When outsourcing, it is critical to research thoroughly among the various medical & dental billing companies in USA and select a healthcare service partner that has been in the business for the longest time transforming the patient experience and financial performance of the healthcare organization.