Most Common Medical Billing Questions

(Updated April 2025)

Medical billing can feel overwhelming, even for experienced healthcare providers. Between navigating complex insurance plans, understanding coding systems, and figuring out patient out-of-pocket costs, it’s no wonder so many medical billing questions arise. Providers want to focus on delivering quality care—not getting bogged down by paperwork or chasing payments from insurance companies.
At MBA Medical, we hear a lot of the same questions from clinics, hospitals, and private practices. Below, we’ve compiled some of the most common medical billing questions to help you make sense of this often-complicated process.

Common Medical Billing Questions

Whether you’re a small clinic or a large network hospital, understanding these common medical billing questions is key to keeping your practice running smoothly:

1. What is medical billing and why is it important for my practice?
2. How does the coding system work in medical billing?
3. What’s the difference between in-network and out-of-network billing?
4. How do insurance companies determine what they will cover?
5. What are patient out-of-pocket costs and how are they calculated?
6. What is balance billing and when does it happen?
7. What should I do if a patient can’t afford their medical bill?
8. How do assistance programs work and can my practice help patients apply?
9. What is the role of health insurance in the billing process?
10. Can patients pay with a credit card and how do we set that up?
11. How do I handle billing questions from patients?
12. What happens if a claim is denied by the insurance company?
13. How do I ensure my practice is paid quickly and correctly?
14. What reporting should I expect from my billing service?
15. How can a third-party billing company help my practice?
16. What is a deductible, and how does it affect medical billing?
17. How does prior authorization work, and why is it important?
18. What’s the difference between a copay and coinsurance?

1. What is medical billing and why is it important for my practice?

Medical billing is the process of submitting claims to health insurance companies to receive payment for healthcare services you’ve provided. It ensures your practice gets paid for your work—whether from insurance plans, patient out-of-pocket costs, or a combination of both. Without efficient medical billing, your revenue cycle slows down, which can affect your cash flow and your ability to care for patients.

2. How does the coding system work in medical billing?

Medical billing uses a detailed coding system to describe every diagnosis, treatment, and procedure. Common codes include ICD (International Classification of Diseases) for diagnoses and CPT (Current Procedural Terminology) for services performed. These codes help communicate exactly what happened during a visit so insurance companies know what to reimburse. Mistakes in coding can lead to denied claims or underpayment, so accuracy is critical.

3. What’s the difference between in-network and out-of-network billing?

When your practice is part of a patient’s insurance plan network, you’ve agreed to certain rates with that insurance company. This is called in-network billing. If you’re out of network, you haven’t negotiated rates, and the patient may be responsible for higher out-of-pocket costs. Patients typically pay less when visiting in-network providers, so it’s important they understand the difference.

4. How do insurance companies determine what they will cover?

Insurance companies review each claim against the patient’s specific plan. They check to see if the service is covered, medically necessary, and performed by an in-network provider. Every plan is different, which means one patient’s insurance might cover a service completely, while another’s won’t. They also look at deductibles, copays, and coverage limits before deciding how much they’ll pay.

5. What are patient out-of-pocket costs and how are they calculated?

Out-of-pocket costs are what the patient pays after the insurance company covers its share. This includes copays, deductibles, and coinsurance. The amount depends on the patient’s insurance plan, the provider’s network status, and the total cost of care. It’s helpful to estimate these costs upfront when possible, so patients aren’t surprised later.

6. What is balance billing and when does it happen?

Balance billing happens when a provider bills the patient for the difference between what was charged and what the insurance paid—but it’s not allowed in every situation. For in-network services, balance billing is usually prohibited because you’ve agreed to the insurance company’s rates. However, if you’re out of network, you might balance bill the patient unless laws or contracts prevent it.

7. What should I do if a patient can’t afford their medical bill?

It’s a common challenge. Many practices offer payment plans or connect patients to assistance programs designed to help cover costs. Some hospitals also have charity care programs for qualifying patients. The key is to talk openly with patients about their options so they don’t avoid care out of fear of the bill.

8. How do assistance programs work and can my practice help patients apply?

Assistance programs—like state Medicaid, hospital charity care, or pharmaceutical assistance programs—help patients pay for medical services, medications, or supplies. Your staff can help screen patients for eligibility and assist with the application process. Providing this support helps patients access care while reducing bad debt for your practice.

9. What is the role of health insurance in the billing process?

Health insurance acts as a third party that helps cover the cost of healthcare services. After a visit, your office sends a claim to the insurance company, which reviews it and pays its share based on the patient’s plan. The insurance company determines how much the patient owes, what’s covered, and if any services need prior approval.

10. Can patients pay with a credit card and how do we set that up?

Yes! Many patients prefer paying with a credit card because it’s fast and convenient. Setting this up is simple—you’ll need a merchant account and payment processing system that allows for in-office or online payments. Offering multiple payment options can improve collections and make things easier for patients.

11. How do I handle billing questions from patients?

Patients often have billing questions about what they owe or why something wasn’t covered. It helps to train your front desk or billing team to explain charges clearly and answer common concerns. Providing easy-to-understand statements and being available to answer questions builds trust and helps avoid frustration.

12. What happens if a claim is denied by the insurance company?

Claim denials happen for many reasons—coding errors, missing information, or lack of coverage. When this happens, you can appeal the denial by correcting the issue or providing more information. Working with a knowledgeable billing team ensures denials are caught quickly, corrected, and refiled, so you get paid.

13. How do I ensure my practice is paid quickly and correctly?

The best way is to have solid billing processes in place—accurate coding, timely claim submission, and thorough follow-up on unpaid claims. A professional billing company like MBA Medical tracks everything, follows up on delays, and makes sure your practice is paid as quickly and correctly as possible.

14. What reporting should I expect from my billing service?

Your billing service should provide regular, detailed reports showing collections, outstanding claims, and patient balances. These reports give you a clear picture of your financial health and help you spot trends or problems. Transparency is key—you should always know where your money is in the process.

15. How can a third-party billing company help my practice?

A third-party billing company handles the heavy lifting of medical billing, insurance follow-up, and patient billing. They bring specialized knowledge, advanced technology, and a dedicated team focused on improving your cash flow. By outsourcing, you save time, reduce errors, and free up your staff to focus on patient care instead of paperwork.

16. What is a deductible, and how does it affect medical billing?

A deductible is the amount a patient must pay out of pocket each year before their health insurance starts covering services. Understanding a patient’s deductible is important because it impacts how much the insurance company pays and how much the patient owes. Patients often have questions about this, so it’s helpful to explain it clearly upfront.

17. How does prior authorization work, and why is it important?

Prior authorization means a healthcare provider must get approval from the insurance company before performing certain procedures or treatments. Without it, claims may be denied—even if the service was medically necessary. Keeping track of prior authorizations is critical to avoid delayed or denied payments.

18. What’s the difference between a copay and coinsurance?

Both are forms of patient out-of-pocket costs, but they work differently. A copay is a fixed amount the patient pays at the time of service (like $30 per visit), while coinsurance is a percentage of the total cost (like 20% of a hospital bill). Helping patients understand the difference prevents confusion and billing issues later.

Get Help Answering All Your Medical Billing Questions

Medical billing doesn’t have to be a constant headache. With the right support, your practice can navigate insurance plans, patient out-of-pocket costs, assistance programs, and coding systems with ease. Having trouble answering these questions—or just tired of the paperwork? Reach out to MBA Medical.

With more than 25 years of experience, we handle the complexities of medical billing so you can focus on what matters most: caring for your patients. Contact us today to learn how we can help your practice thrive.