Introduction:
A medical claim is a bill submitted by the doctor to the patient’s health insurance company for services provided. In medical billing, the claims preparation process entails translating patient interactions into correct, timely invoices, submitting them to payers, and evaluating them to ensure they are fully paid. Physicians must submit claims or bills to commercial and federal health insurers to pay for services provided to covered patients. Claim filing in medical billing entails multiple complex procedures, and getting them is critical to maximizing reimbursement.
Steps For Preparing & Submitting A Medical Claim
Following are the essential steps for preparing and submitting a medical claim.
Patient Registration:
Patient registration is the first step in the claim submission process in medical billing. Primary patient data is collected at the front end of the medical billing process, such as:
- Patient demographic data (i.e., personal and contact information)
- Appointment scheduling or patient referral
- Health history of the patient
- Verification of insurance eligibility
Medical Billing & Coding:
After the patient checks out, the back-end medical billing process begins. The medical coder receives the medical report from the patient’s visit. Medical coding includes extracting billable information from the medical record and clinical data. When a patient visits a physician’s office, hospital, or another healthcare facility, the visit is documented in the patient’s medical record, along with the purpose for providing specific services, products, or operations. Medical coders analyze clinical paperwork and assign the appropriate ICD-10 codes for diagnosis, whereas CPT and HCPCS codes for services provided. Expert medical coding services can help expedite the process while ensuring coding accuracy.
Financial Responsibility
The next stage is to ascertain who is financially responsible for the visit. That entails reviewing the patient’s insurance information to see whether procedures and services are covered during the visit. The patient is informed about their financial responsibility if any processes or services are not covered.
Preparing the superbill:
The patient’s insurance plan and payer restrictions determine whether a procedure is billable. Charge entry includes entering charges for services rendered into the practice management system and payments made by the patient at the time of service. Superbills, generated from medical codes and patient information, are used to prepare claims. The superbill will comprise information about the healthcare provider, the patient, and the visit – medical codes, modifiers, place of service codes, time, units, amount of items utilized, and insurance authorization information. To demonstrate the medical necessity of services, physicians might add objective and supportive evidence in the superbill.
Generating Claims
The medical biller will then use the superbill to produce a medical claim to be submitted to the patient’s insurance company. Once the claim is prepared, the biller must carefully review it to ensure that it fulfills payer and HIPPA compliance criteria, including medical coding and format requirements.
Claims Scrubbing:
Billers will examine codes during the medical billing insurance claims process to ensure that the services/procedures coded are chargeable. They will also scrub the claims to ensure that no errors exist. This procedure entails scanning claims for the following items:
- Procedure accuracy, as well as related diagnosis and procedure codes
- Data from patients and providers
- Data from insurers
- Medical need
- Procedures based on age and gender
- Medicare, Medicaid, and other information
Errors are instantly rectified if they are discovered. Claim scrubbing produces more accurate claims and decreases the probability of denial.
Claim Submission:
Claims are submitted on forms appropriate to the payer. Following different types of claim forms are used by Medicare and private insurance organizations:
- Medicare claims are submitted using the CMS-1500 form for physician practices.
- CMS-1450 or UB-04 form for hospitals.
Private payers, Medicaid, and other third-party payers may utilize various claim forms based on their specific needs or claim forms based on the CMS standard. Submitting a clean claim in medical billing also entails adhering to billing compliance rules such as HIPAA. Once shares are completed, they will be filed to the insurance company through a third-party vendor, such as a clearing house or a medical billing business.
Adjudication of Claim Monitoring
Adjudication is the process through which payers assess medical claims to determine if they are valid and compliant and, if so, the provider will receive the amount of compensation. During this stage the claim may be approved, rejected, or refused. An accepted claim will be reimbursed under the insurer’s agreements with the supplier. A denied claim contains errors that must be rectified before the claim can be resubmitted. A refused claim is one that the payer refuses to refund.
Preparation of a Patient Statement
The patient gets billed for any outstanding charges once the claim has been completed. The statement generally provides a thorough account of the operations and services delivered, their prices, the amount covered by insurance, and the amount owed by the patient.
Patient Collections:
The final stage of the medical billing cycle is the patient collection. Medical billers will commence collection actions for patient payments. Accounts receivable (AR) is the amount owed to the provider by patients and payers. Active accounts receivable follow-up that is specific and regular is vital for successful revenue cycle management.
Inefficient processes can result in various issues, including decreased reimbursement, denials, penalties for regulatory noncompliance, and fraud and lawsuit costs. Partnering with an experienced medical billing and coding services provider is a practical method to ensure a smooth procedure and payment for services provided.
