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Medical Billing Process

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Submitted By cspicer0007
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Medical billing is a process that doctors and insurance companies use. Doctors use the process to submit claims to insurance companies so they can be paid for their serves rendered. The billing process consists of 10 steps. These steps have been broken down into three different categories. The visit, the claim, and the post claim.

The first category consists of the first four steps. The first step in this category is “The Visit”. During this step the patient is pre-registered. A returning patient or a new patient is pre-registered by making appointments for a future visit or an appointment to start serves. Each patient upon their visit is as asked for their insurance information and demographic information. Returning patients and new patients are to provide the facility with the medical purpose of the visit.

Step two is to determine what the patient’s financial responsibility will be. The patients insurance usually has a set payment, which is usually 80/20. The insurance will pay 80% of the bill and the patient is responsible for 20% of the bill. For patients that are uninsured, the patient is responsible for all of the medical charges.

Step three, the patient actually gets check-in. Returning patients are asked if all information is still the same as the last visit. Which includes insurance, address, phone number, ect. New patients are asked for all medical and insurance information. All patients are asked for proof of insurance cards and identification, which are photocopied and put into their files. If co-payments are required, that is done according to the facilities policies.

Step four the patient is checked out. If any further appointments are needed or any referrals that need to be made, the patient is giving the necessary paper work and appointments are then made. The patients file is giving to a billing specialist. There all the medical procedures and any medical services that were provided are given special codes and a claim is filed with the insurance company.

The second category consists of three different steps. This category is known as “the claim”. In step five the codes are reviewed for compliance. Medical coding has regulations and rules that have to be met to comply with the insurance company. Each and every medical service that is rendered has a specific code that is placed on each one. This allows the insurance company to identify what services where preformed by the doctor.

Step six to check the billing for compliance. Each visit is assigned a code. The insurance company has a set fee for each code, but not all codes are redeemable for payment. Only the codes that are within the insurance company’s guidelines and rules can be redeemed for payment.

In step seven the claims are prepared and transmitted. Claims made by health care needs to be made in a timely manner. They must also be accurate. The claim includes information about the patient’s services and charges that are being made to the insurance company. Claims are usually transmitted daily or every other day.
The third category consists of the last three steps of the billing process. This category is known as “the post-claim”. Step eight is to monitor payer adjudication. Adjudication means the insurance company is reviewing the medical claim. During this review the insurance company is determining whether the claims that were files should be paid or not. This is also when the company determines how much of the claim they will be paying. Any remaining balance will be paid by other insurance companies, if the patient has coverage under more than one company or by the patient.

Step nine the patients statements are generated. This is when the payments the facility has received from the insurance company are applied to the patient’s bill. The amount of money received from the patient and the insurance company should bring the balance to
-0- (zero). If there is a remaining balance, a bill is issued and mailed to the patient.

Step ten is the last step in the medical billing process. In the last step the medical facility follows up with the patient on paying off any owed balance and handling how the bill will be paid. If the patient is continuously late or nonpaying, a collection process will be filed against the patient.

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