A Comprehensive Guide to Medical Billing Claims Process

A Comprehensive Guide to Medical Billing Claims Process

After a healthcare provider treats a patient, the billing claims process starts. Discover and read this comprehensive guide to the medical claims process.

The medical claims process can seem daunting. This is especially true if paperwork is a low priority, or it’s an unfamiliar process.

Here’s our simple step-by-step guide that will peel away any anxieties your practice may have.

Any medical practice will want quick, accurate, and cost-effective medical billing claims processes for it to be reimbursed as fast as possible. 

Register Your Patients

When someone calls and wants an appointment, and they’re a new patient, they have to provide their insurance details before registering with any medical provider.

A practice must check the patient is eligible to receive medical care from them. Doing this will speed up your medical billing processes right off. 

Responsibility for Payment

Medical insurance differs from provider to provider and plan to plan. It’s essential to establish early on, who handles what when it comes to medical billing.

It’ll save your practice a lot of time. Your practice will need to check each patient’s cover to find out who is responsible for each part of the bill when issued.

In some cases, the patient will have to cover some of the cost and the insurance provider the rest.

When the Patient Arrives

If a patient is new, your practice reception or administrative staff will need to ask the patient to fill out some forms. If they are a regular, then check with them that their details haven’t changed.

The patient must produce a valid insurance card. You’ll also need to ask the patient to show some government-issued photo ID, such as a passport or driver’s license.

Each practice differs in regards to collecting copayments from a patient. Some clinics choose to collect when a patient arrives — others when a patient’s appointment has ended.

When the Patient Leaves

This is when your practice sends the patient’s medical report to its medical coder. This info is taken and put into medical code. It’s vital to enter this information correctly. 

There are common mistakes, practices can avoid, such as over coding, and under coding.

A report is generated. This has data about the patient’s medical history and demographic information. For example, date of birth, gender, and contact information. This is called a “superbill.”

The superbill will show the name of the physician, the patient, why they sought medical attention, and the cost. It also shows the name of the medical practice and the relevant medical codes for the diagnosis and medical procedure.

This bill is then passed to the medical biller. Usually, this sent electronically with a software program, although sometimes it’s done on paper.

Preparing Medical Billing Claims

The practice then sends the bill to the payer. The will cover what the practice expects them to pay. This is according to the patient’s contract with their provider.

Once a practice as generated a medical claim, it is also their responsibility to ensure that the application is format and coding compliant. There are guidelines that practices can follow.

These are by the Office of the Inspector General (OIG) and the 1996 Health Insurance Portability and Accountability Act (HIPAA).

Manual vs. Electronic Medical Billing Claims

The HIPAA requires that all health bodies covered by the Act have to submit claims electronically. But, there are exceptions, so it’s worth checking those.

Manual claims tend to have more errors, take longer to complete, and take longer to process. This saves money, effort, and time. If you’re dealing with big companies such as Medicaid or Medicare, you can send your claim to them.

But, otherwise, this is where we come in to take the billing pain away. Each insurance payer comes with its own guidelines and formats for medical billing claims. We can deal with those for your medical practice.

Evaluation Time

This is where the bill payer adjudicates the claim to decide if it is compliant, valid, and how much to reimburse. It’s at this point that an application may be accepted, rejected, or denied.

If a claim is accepted, this doesn’t mean the entire bill is paid. It just means the funds are settled according to the policy they have with the patient.

Unfortunately, coding errors can lead to the rejection of claims.

If that’s the case, there’s an opportunity to resubmit the application with the correct information. If a patient’s insurance doesn’t cover a procedure, it’s usually denied. This can happen if the patient has a pre-existing condition, for example.

Whatever the decision, the practice will receive a detailed report from the insurance company. This outlines its liability amount and why. Some patients have secondary insurance.

Whatever isn’t covered by their primary insurance can go to the secondary insurance company for a second shot. A practice or patient can enter into an appeal process with the insurance company.

But, this process can be complicated. It’s another reason why it’s crucial to get the coding right the first time around.

Communicating with the Patient

It’s at this point that a statement bill goes to the patient. This shows what the insurance company is paying and what the patient owes.

Getting Paid

Medical bills must be sent out on time and are accurate. If someone’s a late payer, they’ll need chasing with follow-up bills, phone calls or worst-case, a collection agency. Once a patient has paid, this goes on their medical file.

Your practice should be transparent with patients what its payment guidelines are. You can refer to them in case you need to chase someone.

Understand the Medical Claims Process Better? 

The medical claims process doesn’t have to give you or your practice staff headaches. We’re here to make your life easier and to save you time and money. Contact us today to find out how we can help you.