Do you have questions about medical billing? If so, you’re in the right place. Read on for everything you need to know about medical billing.
It’s always good to understand the process of medical billing. When you or someone you know needs medical care, your knowledge will help you make sure everything is as it should be.
The more you know about billing, the more empowered you are as a patient or patient advocate. That’s why we’ve put together this handy guide so you’ll know everything you need. Read on to learn the ins and outs of medical billing.
What is Medical Billing?
This type of billing is the way medical services are paid for in the U.S. Usually, a healthcare provider will submit a billing claim to a health insurance company to be paid for services and procedures.
People can actually become medical billers are a profession. Some U.S. schools offer certificate or associate’s programs in this field.
People who are becoming medical billers are encouraged to take an exam for certification, but it’s not required.
History of Medical Billing
Of course, modern billing for medical services wasn’t always standard practice. For a long time, billing was always done on paper. However, after the internet was developed, health information systems revolutionized the way billing could get done.
Now, many claims can get processed in a short period of time, thanks to this software.
As the systems have changed, they’ve also become more complicated. Now, specialized training often becomes necessary for people to understand modern billing systems.
The Billing Process
Let’s take a close, step-by-step look at the total billing process from start to finish.
1. Appointment Check-in
Billing actually starts when a patient checks in for an appointment. The process can change slightly depending on who actually provides the services; however, to keep things simple we’ll go over a scenario with a .
First, the patient schedules the appointment.
When the receptionist sets the time for the appointment, they often also collect information about the patient. They’ll gather the name, birth date, address, contact information, and visit purpose. They’ll also get the patient’s insurance information.
Now, the office can set up a file for the patient, which will be used for future billing purposes.
These files are important – they keep things accurate and make things move faster throughout the billing process. A good medical office will keep updated files on all their patients to prevent delays and errors.
2. Financial Responsibility Confirmation
After this information has been collected, the office figures out who is responsible for paying for the services provided.
There are many different types of health insurance, from employer-provided to individual. A close look at what kind of insurance the patient has is needed to know who will be responsible for payment.
The office will need to look at the patient’s insurance policy to see what services are covered and approach billing accordingly. Sometimes, insurance plans may require a certain diagnosis before they will cover a service.
Some services are not covered by an insurance plan at all. In this case, medical providers should try to let the patient know that they’re responsible for payment before the services are given.
Different insurance providers also require different types of billing. The office will have to be careful and make sure to meet those requirements so there aren’t any delays in payment.
For example, some services may need preauthorization from the insurance company in order to be covered.
Once these requirements are all met, the healthcare provider should explain the billing process to their patient, including any payments the patient is responsible for.
3. Appointment Check-out
After the health care appointment is finished, billing continues at checkout. The provider will record any services given in the patient’s file. It’s important to accurately record these services because this ensures the bill that gets sent is accurate.
To create these records and send the bill, medical coders will translate information about services given into a code set that operates as a universal healthcare language. These codes simplify the way services are recorded, and make sure things stay accurate.
Once coding is complete, the medical bill can get put together.
Any payments the patient has to make create what’s called the “patient ledger.” This number is made up of any old or new charges, minus payments that got made by the patient or the insurance company already.
The patient is given the remaining amount to pay, usually at check-out time.
4. Billing Compliance
There are requirements medical bills must meet before they can be officially recorded. The requirements change depending on the services provided, the insurance provider, and the medical provider.
However, there are some requirements that always must be followed, such as HIPAA laws.
Compliance is necessary for everything from accuracy to patient privacy. Most of these regulations serve a clear and necessary purpose – they aren’t just random red tape.
The codes that are entered also have to be accurate and billable.
Insurance providers usually have their own set of rules for which codes are billable and which ones aren’t. If the medical biller doesn’t follow the rules, there’s a chance that the bill will be denied until it can be corrected. These unnecessary steps waste time for everyone involved.
5. Claim Transmission and Payment
Once everything is checked for accuracy, the bill can get sent to the insurance company. This is almost always done electronically since it’s faster and more accurate.
Sometimes, this is done through a clearinghouse or medical billing service, instead of directly. The best medical billing service is one that reviews claims and formats them based on the insurance provider’s requirements before submitting.
The insurance company receives the bill and reviews the claim. During this evaluation process, the insurance company decides if it will pay the whole bill, part of the bill, or none of it.
A report containing the decision is sent back to the healthcare provider. If everything is accurate and covered, the payments are applied. If not, more steps may need to be taken – for example, the healthcare office might see if the patient has an alternate form of insurance.
How to Use Medical Billing Knowledge
With this knowledge, you’ll be more empowered the next time you or a loved one receives a bill from a healthcare appointment.
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