The Different Steps of Medical Billing

The Different Steps of Medical Billing

Medical billing is an integral part of the healthcare industry, and those considering this as a career path might be wondering what the job involves. While each medical facility and biller has its own set of processes to follow, there are some basic steps that make up the medical billing process. Following these steps from start to finish ensures accuracy and the prompt payment of invoices sent to the insurance company. 

Patient Registration

Patient registration involves collecting vital information about the patient such as their name, date of birth, address, and brief medical history. Reception staff give the patient a form to complete with questions about their background, family health, demographics, etc. The reason for their visit is also recorded as well as details about their insurance plan. Once all this information is captured, it is the responsibility of the medical biller to ensure accurate information has been provided. 

Verify Insurance

The information provided on the patient’s insurance card must be checked and verified before the patient sees the physician. The insurance company must confirm that the visit it covered and how much they will cover. In some instances, patients will have secondary cover. If so, this insurance company must also be contacted to confirm they will cover the rest of the bill. The patient will be advised if there are any costs not covered by insurance. 

Recording Visit Details

Once the patient has left, details of the visit, including any diagnoses and treatment, will be provided to the medical coder who will translate every aspect of the patient’s visit into alpha-numeric codes. Diagnostic code lookup is just one part of the process. Coders must also match treatments, medications, and administration tasks to their relevant codes. This is made easier by way of online databases, such as those provided by experts on CPT Codes at 

Creating a Claim

Once details of the visit have been entered onto the system, a claim for payment from the insurance company or companies can be created. If the patient is to be billed for any part of the treatment, the biller will need to raise an invoice for this too. 

Submitting the Claim

All claims must be checked for accuracy before they can be sent to the insurance company. They must also be checked for HIPAA compliance and to ensure that they meet the insurance companies’ rules and regulations. Claims are submitted to insurance companies through Electronic Data Interchange (EDI), where they are double-checked for accuracy. Claims may be rejected here for a variety of issues such as missing mandatory fields, invalid information, and non-compliance with the insurance company’s policies. 

Assessment of Claims

Once a successful submission has been made, the insurance company will assess it and determine if and how much of the claim they are going to reimburse. They will either accept, reject, or deny it. Accepting the claim means they are willing to pay all or some of the charges, rejecting means there is an error and it will be sent back to the biller, while denying means they are refusing to pay for the claim (usually because they do not cover the treatment provided). 

Follow Up

Billers must check rejected claims for errors before resubmitting them. For denied claims, the biller may have to follow up with the patient for payment. A statement will be sent to the patient providing details of any payments made by the insurance company with a bill for the amount due along with information about how and when this can be paid. The biller must also follow up with insurance companies for payment once a claim has been accepted.

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