medical billing

How does medical billing system work?

Medical billing is the process through which the healthcare providers get the reimbursement of the services they have provided.  The billers act as a connection between the healthcare provider, payers, and patients.  Without medical billers, healthcare professionals could not get the reimbursement of the services they provide.

Nowadays EMR software has made medical billing much easier. Since medical billing is a complicated and long procedure. EMR software helps in electronic bills generation easily and rapidly. In this article, we are going to talk about how does medical billing system work. Basically, there are eight steps of medical billing.  Those steps are:

Steps of medical billing

  1.  Booking of the appointment
  2. Financial status evaluation
  3.  Check-in and check out
  4. Checking of superbill
  5.  Transfer of claims
  6.  Adjudication
  7.  Patient statement generation
  8.  Record keeping

The above-mentioned steps of medical billing can be better explained as:

1. Booking of appointment

The patient would book the appointment either online or on phone with a healthcare provider. If they have previously visited the doctor, they do not need to provide any information other than the medical record number. Otherwise, if they are a new client, they have to give complete personal details and insurance details for booking an appointment. They would not need to give their details again and again. Instead, it would be saved on the EMR software.

2. Financial status evaluation

The financial status evaluation involves ruling out who will pay for the bill. The biller should rule out either the patient can avail of the service reimbursement or not. Medical billing perks vary according to different insurance companies and different packages. Like some packages do not involve the medicines or lab tests reimbursement. While some offer a whole reimbursement package. This strongly depends upon what kind of package you have opted for.

If the availed services are out of the insurance package coverage, Then, in this case, the patient would pay it from his own pocket. The biller must inform the customer that they would have to pay it on their own.

3. Check-in and check out

When the patient arrives at the doctor’s office, they have to fill a form and give their complete details upon the first visit. Moreover, when they check out, they will have to fill the form on which the doctor has written their orders, upon the first visit. They would not need to fill the forms on the next visits, because their information would be saved already. Also, they would require to show any identification document like a national identity card or a driving license along with a valid insurance card.

Furthermore, they will have to pay a copayment at the time of the doctor’s visit or at the covered pharmacy medication. Co-payment is a small amount of money that you have to pay at the time of the visit. Then your insurance company would pay the remaining 100% money to the healthcare provider.

When the patient checks out from the hospital, their report is sent to a medical coder. Where the medical coder turns it into a superbill. The superbill is a document that contains the detail about the patient, name of the physician, the procedure performed, diagnosis, history, and other medical information. Since this document contains the whole information, it helps in getting the claim. Moreover, the superbill is transferred to the medical biller.

4.  Checking of  superbill

The fourth step of billing management includes the rechecking of the superbill. The medical biller transfers the superbill to the medical coder after transforming it into a paper claim form or through a billing management system. Medical billers would also include the cost of the procedures in the claim.

After the creation of the medical claim, the biller is responsible for the authenticity of the prepared claim. He or she would make sure that the medical billing is done in a perfect and transparent way.  The medical coder is responsible for the efficient coding process. But the biller does cross-check to make sure that billable procedures are included in the bill.

It totally depends on the patient’s insurance plan and insurance company about either the procedure is billable or not. This is because every plan has a different cost and different coverage. So the coverage of the procedures varies according to the type of plan you choose.

5. Transfer of the claims

The claims are then transferred to the payer. This can be done either manually or electronically. But the manual transfer of claims has many drawbacks. Someone has to go in person to send the records. Also, it is time taking and not enough efficient. Electronic transfer of claims can be done in minutes and saves time for overall medical billing.

6. Adjudication

The sixth and one of the crucial steps of medical billing is adjudication. After making the claims, they are reached to the insurance companies or the payer. Overt there, the payer evaluate the claims and check either the claims are billable or not. This process of rechecking the claims is known as adjudication. At the stage of adjudication, the claim can be either accepted, rejected, or denied.

The accepted claim means that the claim made is billable. The insurance companies bill them according to the rules and regulations of the contract. The rejected claim means that the claim made is not billable. Or there is any information missing or any unbillable procedure is added. In this case, the payer sends it back to the provider.

Healthcare providers can reclaim the bill by correcting it and sending back to the insurance company. The third type of medical billing claim is a denied claim. This means that the payer would not pay for the bill. This happens because there is any procedure or service that has not to be paid by the insurance company. Since the health service coverage strongly depends upon the type of package you have chosen from the insurance company.

After the adjudication is done, the payer sends a complete report to the biller, along with the amount of payment and the reason of doing that. The biller would review all the procedures and make sure that everything is done correctly.

7. Patient statement generation

Furthermore, the payer sends the complete report to the biller. Then they generate a patient statement. This includes a complete record of all the covered procedures and services. After that, the patient gets the remaining amount from the payer, when the insurance company agrees to pay the provider.

8. Record keeping

In the last and final step of medical billing, the biller keeps the complete record of the patient’s bill. They also make sure that the payment is done in a good manner. Biller is responsible to get the reimbursement done for the healthcare providers.

Conclusion

Medical billing is a long and bit complicated procedure. However, if EMR software is used to make the bills, medical billing can be made a bit easier. InstaCare is providing a low cost, reliable, and efficient EMR software that would make your bills generation easy and quick. For more information, please contact InstaCare.