6 Key Steps of a Successful Medical Billing Process

Touseef Riaz

March 3, 2021


If you run a medical practice, you know that medical billing is an important process that ensures your medical practice runs smoothly without a hitch. It is no secret that the medical billing and coding process is long and complicated in most cases. However, the good news is that with a suitable billing plan, your practice can run efficiently and smoothly without any hassle.

Also, it is worth noting that the medical billing process helps ensure that all parties in healthcare, such as doctors, patients, and insurance companies, are paid as well as appropriately credited. We can also say that the billing process makes sure that doctors and healthcare professionals receive payment, either from the patient or the insurance company.

Did you know that a well planned and effective medical billing and coding process helps create a medical claim? You should know that many steps are involved and repeated in the process. As a result, it often causes a delay in payment. And this is one of the reasons you should work with experts and professionals in the field. 

Also, it is worth noting that medical billing professionals need to comply with all HIPAA regulations and guidelines in order to prepare reliable and accurate medical claims. Did you know that a medical claim transits completely through the entire revenue cycle management? As a result, it helps prevent redundant procedures from overlapping the schedule while expediting the medical claim submission procedure.

Note that depending on the circumstances and situation, the process can take a matter of a few days to complete, or it might stretch over many weeks or even months. Here are the 6 key steps of a successful medical billing process in an organization.

1. Patient Check-in or Registration

Note that this is the first stage of a patient’s appointment. This step involves collecting the patient’s demographic information, such as age, as well as information about their insurance, such as the insurance payer and insurance policy number. 

During this step, patients complete the various forms and confirm all their information on the medical file (if it is not the first visit) on their arrival. It is worth noting that along with completing the forms, patients must also provide some official identification, like a driver’s license, passport, in addition to the insurance card.

Keep in mind that if the patient has seen the medical provider before, then their information is likely on file. As a result, the patient only has to explain the rationale for their visit. It is worth noting that your staff must collect all details and essential information that your practice requires for claim submission.

On the other hand, if the patient is new, they must provide personal as well as insurance information to the provider in order to make sure that they are eligible to receive medical services from the provider.

2. Verify Insurance Information

Did you know that many regular patients have to verify their information as well as eligibility before every medical appointment? Note that as insurance information may change at any time, this can impact the benefit as well as authorization details. This is why you have to ask your patients before each visit if their information has changed.

Note that insurance verification is the method that verifies insurance claims in order to avoid denials or fraud. Also, keep in mind that it requires knowledgeable and experienced professionals to contact the insurance payer to verify all insurance claims.

There is no doubt that wrong, obsolete, or changed information can considerably impact the benefits. This is why you should double-check your patients’ information. Also, note that if there are services or procedures that won’t be covered, you must inform the patients that they will be personally responsible for these costs to avoid any issues later.

3. Medical Coding of Diagnosis, Modifiers, and Procedures

Note that medical coding fixes the diagnosis as well as the procedure codes during this step for patients on the basis of some standards. Some of these standards are ICD-10 and CPT. It is worth noting that the 5-digit procedure code indicates the medical service used.

On the other hand, the diagnosis code helps determine the doctor’s diagnosis. It is vital that your medical billing staff record every medical service that you provide in a medical code. The staff should also encapsulate every tiny detail into standardized codes in order to ensure accurate and timely medical billing.  

You should know that the correct and timely coding of medical claims is essential for informing the insurance company of what the patient is being treated for and the treatment method that the patient is undergoing.

Also, accurate medical coding information is used for describing the patient’s illness or symptoms and defining the most suitable treatment as well as diagnostic procedures. This is why medical coding professionals have to use the standardized guidelines of HCPCS and CPT code modifiers. Did you know that the insurance payer can only make a reliable and accurate assessment if you use the correct medical codes and modifiers?

4. Charge Entry

This simply means charging your patients for the medical services that they have received. It is worth noting that charge entry includes appropriate linkage of medical codes to medical procedures as well as functions during patients’ visits. 

Note that expenses you incur in order to provide the medical services or the collectible amount (maximum) are added to the medical charges coded by your coding team. And it is worth noting that this is one of the key steps in preparing the medical claim form that you have to submit to the insurer.

It is important that professionals monitor the system in order to make sure they add the correct value. This is because an error or mistake may lead to reduced payment on the medical claim.

5. Claims Submission

After you complete the claim process, you have to submit the claim to the insurance company for reimbursement. Keep in mind that the individual involved in the medical billing procedure should be able to access all the details that they require. After all the essential data is collected, professionals prepare medical billing claims.

Did you know that medical billing professionals have to consider every variable for each insurer in determining when and how to submit a medical claim? The medical claim will be transmitted electronically to a clearinghouse in most cases. Note that a clearinghouse is a third-party provider that acts as a liaison between health insurers and healthcare providers. The only exception to this rule is high-volume payers, like Medicaid, who will accept medical claims directly from healthcare providers.

Although most healthcare insurance providers follow a standardized set of guidelines for effective medical billing, note that some co-pays tend to follow their regulations to do things. It is important for medical billers in your organization to focus on specific aspects that are payer-specific. For example, they have to ensure they are accurately following all their guidelines for medical claim submission.

6. Receive and Post-payment

Note that once the insurance provider decides to pay the medical claim, they will release the payment either in the form of a paper check or electronic fund transfer. The latter is mostly bulk payments, and with it, the company shares the summary. The summary is known as EOB (Explanation of Benefits) or ERA (Electronic Remittance Advice).

If you submit the claim properly and timely, the insurance provider will send the payment to your medical practice. After that, the medical coder will post the payments to your practice’s account. Did you know that medical coders are also responsible for fixing claims that have errors?

They also follow up on late payments. It is worth noting that professionals handling the payment have to post the payment entries in the EHR as well as tally the payment received.

Final Thoughts

Although most companies usually follow a standard set of rules and guidelines for medical billing, there are many payers who rely on other ways of doing things. As some aspects of medical billing are very payer-specific, it is essential to check each payer in order to make sure you’re accurately following all their regulations and rules for medical claim submission. 

It is best for healthcare practitioners to follow these six key steps for successful and efficient medical billing. Note that the medical billing procedure starts as soon as a patient visits your office. There is no doubt that following these 6 steps will ensure a smooth and hassle-free medical billing experience for your medical practice.

Note that your front desk staff collects essential information, such as insurance information, from the patients during preregistration. After that, medical billing and coding specialists translate this information into standard codes. Professionals use these medical codes to generate billing claims. And accurate medical claims are forwarded to insurance companies for reimbursement.

If you think that your medical practice cannot handle this process, you can work with the best billing professionals, such as UControlBilling. Contact UControlBilling for more information on how the company can help you make your medical billing process as simple and efficient as possible. 

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