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How does the medical billing cycles work

How Does The Medical Billing Cycle Work?

Medical billing deals with submitting healthcare claims to insurance companies to get paid for medical services given by healthcare professionals. Medical billing cycle can take few days or even a couple of months, depending on the complexity of services performed and the management of claim denials. Errors at any billing cycle can be costly in revenue and operational workload, emphasizing the importance of medical billers understanding their role in the billing process. The performance of medical billing employees is critical to the financial health of physician practices and provider organizations such as hospitals, health systems, and surgery centers. Following are the essential steps in a successful medical billing process:

Patient Registration

The first step of a patient’s visit should include noting the patient’s demographic details and insurance information, such as the insurance payer and reference number. Any data that is relevant and necessary in a claim situation should be provided in detail at patient check-in.

Insurance Verification

Insurance coverage varies significantly between organizations, individuals, and policies, and the biller must verify each patient’s insurance to issue the bill appropriately. Healthcare professionals should inquire and double-check because it can impact claim processing and reimbursement.

Specific insurance policies do not cover any services or prescription drugs. If patient’s insurance does not pay for the surgery or service, the biller must inform the patient that they will cover the entire bill.

Point Of Service Collections

After determining benefit information during verification, staff informs the patient of their financial responsibilities. That enables the biller to collect the copay, deductible, coinsurance, or the entire sum due while the patient is at the front desk, either during check-in or check-out.

Point-of-service collections are critical in medical billing because they lower the cost of patient balance follow-up and aid in avoiding bad debt and write-offs.

Encounter

A superbill is a form that is created for each patient interaction. The document printed with patient demographics updated includes a list of specific services to record diagnoses. When a patient contacts a healthcare provider, the details of the condition and the service provided are recorded, either in form of audio or video. These details might be documented in front of the patient or after the interaction. It clarifies the condition and prescriptions provided by the healthcare professional. They send information to the RCM firm, which handles medical billing and claims revenue.

Medical Coding

The American Medical Association has established criteria for expert coders to follow for converting medical data into alphanumeric codes. The information contains the following main points:

  • Purpose of the visit.
  • Types of disease.
  • Health care provider administers treatment to treat the condition.
  • The location of provided medical service.

Coders employ CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes to appropriately assign the procedure or service. So insurance payers may quickly determine the amount of payment to be made.

Charge Entry

The cost of providing the service is added to the amount determined by the medical coder. That is the first process of preparing the claim form forwarded to the insurance provider, and the payment cannot be captured unless a specific amount is provided. The claim form is checked correctly to ensure that the proper amount is stated. In case of an error, insurers deny or reject claims, disrupting the revenue cycle and increases the rate of accounts receivable (AR).

Claim Submission

Once the claim process has been completed, submit the claim to the insurance provider for reimbursement. Please remember that the party involved in the medical billing process should have access to all the information. The insurance provider also validates the patient health information, checks to see if the plan and action are in order, and looks for coding errors. If there are any inconsistencies, the claims are rejected and returned to the healthcare practitioners.

Monitor Claims

Adjudication is the procedure by which payers analyze medical claims to verify whether they are accurate and compliant. If the proper claims are submitted, then the amount will be reimbursed to the provider. There are different cases, whether the claim is accepted, rejected, or denied. A claim that is taken will be paid under the insurer’s contracts with the provider. A rejected claim contains errors that must be corrected before the claim can be resubmitted. A denied claim is one that the payer declines to pay.

Patient Statement Preparation

Once the claim has been handled, it’s time to make the patient statement. Statement contains a thorough list of the processes and services offered, their costs, the amount paid by insurance, and the amount owed by the patient. In some cases, a biller may include an Explanation of Benefits (EOB) with the declaration. An EOB outlines the benefits and thus the type of coverage a patient gets under their policy. EOBs can help patients understand why specific processes were covered while others were not.

Patient statement Follow-up

The final step in the medical billing process is ensuring all bills get paid. Once an invoice has been paid, information is stored in the patient’s file. It is the biller’s responsibility to make sure that the provider is adequately reimbursed for their services. Medical billers must contact patients whose payments are due and, if required, refer accounts to collection agencies.

The Importance Of Revenue Cycle Management In Medical Practice

Revenue Cycle Management is essential for streamlining tasks and ensuring the smooth operation of the medical practice. Sophisticated management software is required to simplify critical functions such as scheduling, medical billing, coding, claim submission to insurance companies, and payment collection.  Slight error in entering correct patient information or assigning incorrect codes can disrupt a medical practice’s revenue flow.

Documentation is critical in revenue cycle because insurance companies can only reimburse the medical practice if the medical bills are correctly handled. Medical information should be carefully managed and monitored to guarantee that healthcare professionals such as doctors, nurses, physicians, lab technicians, therapists, and social workers are adequately paid.

Medical information includes the following:

  • Classification of disease.
  • Medical procedure conduction
  • Utilized medical supplies or equipment.

 

Medical billing is the crucial component of a healthcare system to ensure that the data are appropriately tracked and that there is a consistent flow of information between healthcare providers and insurance companies.

The Importance Of RCM

Conclusion 

Hiring third-party qualified medical billing companies to manage your claims is the most cost-effective solution for most healthcare providers. We offer medical billing services to effectively submit claims and follow up on insurance claims to save time.

Our team is familiar with specific payers and can work diligently, knowing about a company’s specific policies, to obtain payment in the shortest amount of time. We follow up on denied claims and pursue delinquent bills. Benefits of using our billing services are as follows:

  • Improved and faster workflow.
  • Deal with specific payer payment policies efficiently.
  • Reduce errors in claim processing and submission.
  • Extensive follow-up is performed to ensure proper reimbursement.
  • Streamlined revenue cycle management.
  • Effective claim processing.

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