Medical Billing Process Steps

July 7, 2022

Medical Billing Process Steps

Medical billing is the process of collecting payment from insurance companies for services provided by doctors and other healthcare providers.

The process involves several steps, such as submitting claims to insurance companies, receiving payments, and then remitting those funds to the provider.

The following guide gives an overview of how the medical billing process works.

The Steps Involved In The Medical Billing Process

The below process can take any length of time from a few days to a number of months, the duration of which is impacted by the circumstances.

Processes may vary between different medical offices however below is a general overview of the steps that are completed during the medical billing process.

Patient Registration

The first step in this process starts when the patient arrives at your practice.

With patient registration, you are checking the patient in and also collecting important basic data regarding their demographic, including name, date of birth, and the reason for the visit to your practice.

During this step insurance information is also collected, this includes collecting the patient’s policy number and the name of their insurance provider.

This is then verified by medical billers to ensure the patient has not given false information.

All of this information that has been gathered during this step is then used to set up a patient file that acts as a point of reference during the medical billing process.

Confirm Financial Responsibility

Determining who is financially responsible for the patient’s visit to the practice is the next step in this process.

To do so the patient’s insurance details will be looked over to find out what services and procedures are covered.

If the treatment plan for the patient is not covered by their insurance policy then the patient is made aware that they are financially responsible for any costs accrued.

Superbill Creation

When visiting a practice for the first time, or if the patient is a returning patient who has previously visited or sought medical assistance, they will be asked to complete forms or update information on the file the practice has.

Identification will be used to verify the patient’s name and a valid insurance card will also need to be presented.

A co-payment will also be collected at this time.

Once the patient is checked out the medical reports generated from the visit are translated into codes related to specific diagnoses and procedures by a medical coder.

The ‘superbill’ is created using all of the information gathered up to this point.

Prepare Claims And Check Compliance

Using the information on the superbill a medical biller next begins to prepare a medical claim which will be submitted to the patient’s insurance company.

The biller is obligated to go through the claim carefully after creating it to ensure it meets HIPAA and payer compliance.

The claim must also be created to reach the standard expected of both the medical coding and format also.

Claims Submission

Now the claim has been prepared and checked for compliance the claim is submitted.

In most cases, the claim is submitted electronically to a clearinghouse.

A clearinghouse is an external third-party company that liaises between health insurers and healthcare providers.

Claims are directly submitted to healthcare providers for high-volume payers such as Medicaid.

Monitor Adjudication

In this next step, a layer evaluates medical claims to then ultimately decide how much valid and compliant claims should be reimbursed.

This step is called adjudication. Claims can be both accepted or rejected during adjudication.

When a claim is accepted it is paid according to the insurer’s agreement with the provider.

If a claim is rejected this may mean that there are errors within the submission and the claim then needs to be resubmitted.

Claims can also be denied during adjudication and in this instance, reimbursement is refused.

Patient Statement Preparation

A patient statement is a detailed list that includes what services and procedures have been provided, how much they cost and the amount that was paid by insurance, and what is owed by the patient.

Money owed by patients is a result of outstanding charges or costs that are not covered within their policy, and these additional costs are charged for after the claim has been processed.

Statement Follow-Up

The final step in this detailed process is purely to ensure that all bills have been paid.

It is the responsibility of the medical biller to follow up with patients whose bills have not yet been paid and in some cases, collection agencies may be involved in cases where bills are delinquent.

Additional Steps

Additional Steps

Some medical practices may have additional steps that allow them to ensure the medical billing process runs efficiently and that the practice does not fall victim to fraud.

These steps include:

Maintain Compliance

Maintaining compliance with state laws and regulations requires that you keep accurate records of your patient’s health care needs.

For example, you must maintain records of patient demographics, diagnoses, treatments, and outcomes.

Ensure that your paperwork is kept in order to avoid any errors.

Stay Informed

Stay up-to-date on changes in federal and state regulations.

This includes changes in HIPAA privacy rules, requirements for electronic recordkeeping, and changes in tax law.

Avoid Fraud

Fraudsters often target medical professionals, so stay alert to suspicious activity.

Report any fraudulent activities to the appropriate authorities.

Follow Up

Follow up with patients after they leave your office.

Make sure they understand what was done during their visit and also make sure they know where to go next if they have questions.

Some practices will also ask for feedback from patients about their experience with the practice.

This helps medical practices to improve patient experiences with future visits.

Final Thoughts

The medical billing process is a very detailed process and it is critical that all steps are carried out in line with the law and without any error.

The medical biller is responsible for a lot of the main steps within this process but for all parties involved, including the medical practice and patient, it is essential that paperwork is kept in order to prevent any errors or delays in this process.

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About the author 

Fred Hopkins

Fred has been connecting medical practices with qualified medical billing and coding professionals since 2016. Helping doctors, of all kinds, streamline patient operations along the way.

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