Medical_Billing_Process

Steps in the Medical Billing Process Amanda Splan HCR/220 February 12, 2012 Deborah Ryan Steps in the Medical Billing Process Medical billing specialist must follow steps in the medical billing process to complete their duties. These steps are important to follow to ensure accurate, appropriate, timely payment for the patient’s medical services. The first step in the medical billing process is to pre register patients. In this step of the process the medical billing specialist schedule’s and updates appointments for new and old patients. They ask new patients for basic personnel and insurance information, and both new and old patients are asked for the medical reason for the visit so that they can schedule the appropriate visit for them. This step is to basically get all the personnel and insurance information on the patient and to find their medical reasons for scheduling the visit and making sure that all information is accurate and correct for each patient. The second step is to establish financial responsibility for the visit. This is an important step and there is a set of questions that need to be answered for all patients. The medical billing specialist must determine what services are covered under the patient’s plan, and what medical condition establishes medical necessity for the services. They also must determine what services are not covered, what the billing rules are of the plan, and what the patient is responsible for paying (Valerius, Bayes, Newby, & Seggern, 2008). By knowing the answers to these questions it will help to correctly bill insurance companies for the services for the patient and to know if the patient will have to pay a fee out-of-pocket for some services. This process helps the billing specialist verify the patient’s health plan and coverage of the health plan. This helps the billing specialist to correctly bill insurance companies and patients for services. Checking in patients is the third step of the process. In this step returning patients are asked to review their information on file to make sure that it is accurate and up-to-date and their financial information is checked to make sure that there are no balances due from previous visits. New patients arrive demographic and medical information is collected from the patient and all patients ID’s and insurance cards are scanned or photocopied and placed in the patients file. At this point of the check in process if there are any additional forms that must be completed such as authorizing planned procedures and payments, these are also completed as well. All copayments are due at the time of the visit as well. Checking out the patients is step four of the medical billing process. This process is completed after the patient has seen the physician. The first thing done in this process is to record medical codes for the visit. Medical procedures and diagnosis are assigned a medical code in order to bill for the services. Some facilities the physician assigns the medical code and some facilities the medical billing specialist will assign the codes. The patient’s illness is assigned a diagnosis code and the procedure the physician performs is assigned a procedure code. This information is used by the medical billing specialist to update the patients account. Step five of the medical billing process is reviewing code coding compliances. In this process there are guidelines that must be followed for each code assigned. Once procedure and diagnosis codes are selected the must be double checked for errors. If there is an error when entering these codes in could mess up the patient’s record and cause the patient and the insurance companies to be billed for the wrong services and diagnosis. Each procedure and medical diagnosis entered in the patients file needs to be logically linked so that the payer understands the medical necessity of the charges. If things are not double checked and codes are entered wrong it can become confusing for the insurance companies. Checking billing compliance is step six. When there is a code assigned for a procedure or diagnosis there is a separate fee for each code, but not all codes are billable. Determination of whether a code is billable depends on the payer’s rules. Medical billing specialist must follow the payer’s rules when preparing the claims. They must know the payer’s guidelines to analyze what can and cannot be billed. Step seven is preparing and transmitting claims. This process is an important part of the medical billing process. It is important that all claims prepared accurately and in a timely manner. The claims are prepared and sent electronically to the patient’s insurance company. The claim communicates information about the procedures, diagnosis and charges to the payer. Each practice has a schedule for transmitting claims; some are done daily while others may be done every other day. Monitor payer adjudication is step eight of the medical billing process. This is the step where the payer reviews the claims by putting them through a series of steps to decide whether the claim should be paid. This process is known as adjudication. The payer decides whether the claim should be paid in full, pay some of the claim, or to deny it, and they explain their decision on the back of the report sent to the provider with the payment. The payment is to be collected as soon as possible from the payers and patients who pay out-of-pocket so that the payments can be applied to run the practice. Step nine is to generate patient statements. The patient statement is made and sent to the patient. In the statement is a list of dates, services provided, payments made by the payer and patient, and a list of balances still due. When the payer makes a payment the payment is applied to the correct patient account so that the practice can generate the statement to be sent out to the patient. In some cases the payer does not fully pay the full amount of the bill, and the patient will be billed for the remaining balance. This is why statements are made for the patients and sent to them. The very last step in the medical billing process is to follow up on patient payments and handle collections. When a patient fails to pay their bill, and it is overdue this is when the patient’s file is turned over to the collections department to get the payment. The practice has a policy to determine when a patient’s payment is due and once the patient’s payment is later than permitted by the policy they hand it over to the collections department to handle it. Every step in the medical billing process is very important. Following each step in the correct order helps the process to go smoother and helps to avoid errors. If any errors are made in any step of the process it can cause patients and insurance companies to be billed for the wrong services. These errors can cause a delay in payment to the practice. Reference Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical Insurance: An integrated claims process (3rd ed.). Boston: McGraw-Hill.