Similar to medical coding, medical billing is also a pretty complicated and demanding process. The entire process of medical billing comprises several steps leading to the proper reimbursements. It is basically a process of generating medical claims for the services rendered by the healthcare physicians to the insurance carrier. The aim of medical billing is to submit clean claims and get payments for the services provided. A professional and knowledgeable medical biller has a considerable role to play in revenue cycle optimization. The question arises; are medical billing and coding the same thing? The answer is no! Medical coding comprises extracting billable information from the physicians’ notes and translating them into standardized and specific codes.
Significance of Revenue Cycle Management in Healthcare Practice
For streamlining the workflow and cashflows of any medical practice smoothly, revenue cycle management is essential. In order to automate various key functions of healthcare practice, using sophisticated software is required. These functions may include:
- Scheduling appointments
- Medical coding
- Preparing the medical claim
- Claim submission
- And collecting the reimbursements
A hospital or doctor visit is not just a single visit between a patient and a doctor; and it actually comprises a vast amount of paperwork and time. Even the slightest error in patient information, procedure, or diagnosis code can disrupt the entire process when it comes to medical billing. The healthcare practice only runs smoothly and sustains if its revenue cycle is managed effectively.
Steps for Successful Medical Billing
The entire process of medical billing involves the following key steps:
1. Patient registration
Medical billing begins with patient registration, noting down their details, age, gender, and other contact details. Except for personal information, the insurance information of the patient is also necessary for medical billing. It includes the name of the insurance provider, patient policy ID or number, and insurance plan verified by the medical billers.
This entire information is used to make a patient file which can later be updated (if needed) and used in the medical billing process.
2. Insurance verification
Insurance verification is an essential step of the medical billing process. Patients require verifying their information and coverage eligibility. This information should be double-checked before claim generation and submission for proper and timely reimbursements.
3. Determining financial responsibility
Based on the insurance coverage of the patient, their financial responsibility or co-pays are determined. If the insurance doesn’t cover the services, the patient will have to pay the cost on their own. Informing the patient of their financial responsibility beforehand also enhances trust and satisfaction between the provider and the patient.
4. Medical transcription
After the meeting or “encounter” between the patient and their physician takes place, an accurate and detailed medical transcript is developed. The entire patient encounter and information is documented by a professional, which can be later updated if the patient revisits your practice/physician.
5. Medical coding
These medical transcripts and patient encounters are translated into the standardized procedure and diagnosis codes by the medical coder. This report is referred to as a superbill. The medical claim form contains the following information:
- The patient’s demographic information
- Medical history
- Services or procedures performed
- Insurance provider and the NPI (National Provider Index) number
- Place of service code
- The specific procedure (or services provided) and diagnosis codes.
There are specific guidelines provided by the American Medical Association (AMA) for medical coding. Commonly used medical code sets include CPT, HCPCS Level II & ICD-10.
6. Claim generation:
A medical claim is prepared by using the superbill by the medical biller, which is later submitted to the respective insurance provider. After creating a claim, the following information should be verified before submission:
- Payer’s requirements are met.
- HIPAA Compliance
- Coding guidelines are met.
- Standard of medical coding and billing are followed.
7. Claim submission:
Once all the required information regarding the patient-physician encounter is gathered, verified, and entered into the medical claim form, the next step is submission. Before claim submission, ensure that there are no errors in the medical claim, its accuracy as well as compliance.
Claim submission also comprises a couple of steps:
- The claim is transferred into an EHR (electronic health record) software for verification of whether the required information is provided.
- The provided patient information is transferred to a third-party vendor for verification of possible coding errors, DOB, etc.
- After the medical claim is transferred to the respective insurance payer(s), their team also verifies the patient information in the claim. In case of any discrepancies in the medical claim, the insurance payer(s) can deny or reject the claim.
8. Monitor claim adjudication:
Based on the insurance payer’s evaluation of the medical claim, validity and compliance of the medical claim are determined. If the claim is valid, the healthcare provider or physician receives a complete reimbursement/payment based on the agreement. In case the medical claim is denied or rejected, the providers will need to correct the error(s) and resubmit the claim (in case of rejection). In order to prevent any further errors in medical billing, keep track of previously made errors and avoid making them again.
9. Patient statement preparations:
It comprises the benefits and the kind of coverage the patient receives under the plan. Once the medical claim is processed and approved and payment is received from the payer, the patient is billed for the remaining payment (co-pays). In some instances, an EOB is also sent along with the patient statement explaining the reason behind why some services were covered, and some weren’t.
10. Statement follow-up:
The last and final step of the medical billing process is making sure that the medical bills have been paid. Following up with patients and timely mailing out accurate medical bills is the responsibility of a medical biller.
List of denials in Medical Billing
Medical billing and coding come with several challenges and errors, leading to claims being denied or rejected. However, various healthcare providers and physicians outsource their medical billing process to a billing and coding company, which can eventually lead to a lesser risk of errors, more focus on patient care, and higher reimbursements.
Following are the common reasons behind medical claim denials in medical billing and coding:
Missing or incorrect information
Providing complete and accurate information is essential for medical billing. Important information refers to all the information, including personal, medical, demographical, procedure codes, modifiers, and security numbers. Even if one field was left empty, it could increase the risk of claim denial.
Billing for a non-covered service or procedure
Coding guidelines, as well as insurance payer’s requirements, can change over time, and if providers are not up-to-date, it can cause possible claim denials. Based on incomplete knowledge of the insurance payer’s requirements, a non-covered service may be billed, leading to the claim being denied.
Submitting a similar claim again is flagged as a duplicate claim and, therefore, denied.
Late submissions can also lead to claims being denied or rejected. There are several insurance carriers associated with healthcare practice, and everyone with their own deadline dates and requirements. Moreover, each and every one of them also has its own policies for dealing with this situation.
Submitting the claim as soon as possible is beneficial for the revenue cycle management. For this case, medical billing software can be used to notify the provider regarding claim submissions and deadlines. Moreover, it also includes what kind of procedures needs to be followed in case you miss a deadline.
There are some services that can be reported using a single comprehensive code and, in case they are reported separately, can lead to possible claim denials. These codes should not be unbundled for higher reimbursements. Unbundling is categorized as an unethical practice or Medicare abuse.
Use of improper modifier
There are several modifiers in medical billing that are used to provide additional information regarding the code used in a medical claim. Some of the most commonly used modifiers in medical billing include modifiers 22, 25, 59, 91, etc.
Modifier 22 reports that the patient’s procedure took more time or work than typically required. Overusing this modifier eventually increases the reimbursements and revenues of the healthcare practice.
Best practices for medical billing
- Keep a clean claim rate above 95%
- Keep up-to-date with coding changes and guidelines, payer requirements, and deadlines
- Verify patient’s insurance information, coverage, and eligibility criteria (prior)
- Minimize errors in medical coding
- Manage the claim denials and rejections promptly
- Outsource your billing services
Outsource your billing to the top medical billing company
Outsourcing medical billing services might seem like a huge step toward losing control over your billing process. But on the contrary, outsourcing billing services to the hands of professional medical billers and coders have several benefits. These benefits include:
- Reduced risk of errors in medical claims
- A team of highly experienced and dedicated professionals in medical billing
- More focus on providing safe and quality patient care
- Lesser claim denials and higher clean claim rate
- Faster payments and a higher reimbursement rate
- Improved revenue cycle
- Timely submissions and payments.
UControl Billing’s complete medical billing process involves ensuring physicians are being timely reimbursed for the services and procedures rendered. We are a medical billing company in the USA to help you achieve advanced business performance and growth while ensuring patient satisfaction. We get that medical billing and coding are two very critical processes for any healthcare practice, and we are here to be of assistance.
We offer the best medical billing services. Our Medical Billing Services include:
- Fee schedule review and analysis
- Eligibility verification.
- Referrals, Authorization alert, Claim tracking, reduced rejections and denials
- Patient statement processing, Mailing, Customized Monthly financial reports
- Rules-based claim review, scrubbing, insurance follow-up.
- Helping with a collection agency to recover patient balances & always remain HIPAA Compliant
Services we offer:
Revenue Cycle Management (RCM)
Medical Billing Services
Front Office Management Services
Telemedicine Billing Services
Medical Coding Services
Medical Credentialing Services
Medical Transcription Services
Pricing & Plan
“We only get paid when you get paid.”
With UControl Billing, say no to fixed costs. Your billing costs will depend on your monthly receipts, meaning if your production dips down, so will your billing cost. UControl Billing offers two Pricing Plans:
- Medical Billing Only
- Complete Revenue Cycle Management
A couple of years ago, I executed the effective plan of creating a Medical billing and Coding company named U Control Billing. The company aims to bring revolutionary advancements to foster medical billing and coding revenues. As an official member of HIA-LI and MGMA, I feel honored in providing networking opportunities, problem-solving, and improving the revenue management cycle.