As a healthcare provider, you’ve taken an oath to take care of your patients to the best of your ability. But as the owner of a practice, you also need to take care of the financial side of your business as well. As part of your revenue cycle management, it’s important that you or your staff follow the 10 steps in the medical billing process.
Essentially, this process begins when a patient comes to you, either during an in-person visit or remotely (telemedicine for example), and ends once you’ve received payment. There will be communication between you and your patient, you and your staff, and your office and health insurers.
It can seem quite complicated at times–especially if you’re just now starting a private practice. But if you consistently follow the medical billing process, you’ll streamline the process, cut down on errors, and receive payment for your services in a timely fashion.
10 Steps in the Medical Billing Process
These 10 steps in the medical billing process will give the business side of your practice a solid foundation. Mistakes in the billing process cost the healthcare industry (hospitals, insurance companies, private practices, and patients) billions of dollars a year. This process will help keep those mistakes to a minimum.
- Patient Registration
- Verify Insurance
- Record Patient Information
- Send Information to Billing Team
- Apply Appropriate Codes
- Charge Entry
- Review/File Claims
- Insurance Adjudication
- Prepare Patient Statement
- Patient Follow Up/Payment
Whether a patient sees you for the first time or has been seeing you for a decade, every visit needs to include some kind of patient registration. For a first-time visit, a complete medical history should be taken, including demographic information, for record-keeping purposes.
Even if it’s a regular patient, double-check key bits of information (address, phone number, insurance, etc.) to make sure the file is completely up to date. Confirming an address or date of birth from the start will ensure new information is included in the correct patient’s file.
Verify Insurance, Financial Responsibility
During patient registration, make sure to confirm that you have current and accurate insurance coverage on file for the patient. Depending on the visit (worker’s comp, accident, etc.), you’ll also want to know if there’s any secondary that needs to be billed.
This step will allow you to verify that you have the correct insurance information, that the patient is currently covered, and review their out-of-pocket obligations. Confirming this information will help avoid delays and billing errors later on.
Record Patient Information During Visit
During the visit, make sure to take down all of the information shared during the appointment. If possible, record the meeting (audio or video) or take meticulous notes–all of this information will need to be given to a medical coder afterward so the appropriate codes can be applied to the visit.
The meeting can be transcribed after the visit. Make sure the reason for the visit is clear, any diagnoses are included, prescriptions listed, and so on. Not only will this help your coding/billing team, but it will also give your patient a more robust medical history for later use.
Send Patient Information to Billing Team
That medical transcription of the visit, also known as a medical script, is then cleaned up and prepared for the medical billing team. If this is done in-house, you may send the recording to your staff and they can transcribe the notes. If you’re using a third party for your billing, make sure the medical script is error-free.
This is an important step of the process and where many mistakes can occur. If you’re clear, concise, and thorough during the transcription, you’ll make things that much easier for your coders, medical billers, and your patients.
Apply Appropriate CPT Codes
You or your coding staff will assign the appropriate CPT or HCPCS code for the services you performed. Be careful to choose the code that most accurately represents the service performed, and verify the component services aren’t billed separately if they are bundled with the primary procedure.
Next, you or your coders must choose the correct ICD-10 codes for the patient’s diagnoses. And there are a lot of codes: around 68,000 to choose from. The previous iteration (ICD-9) had around 13,000 codes to choose from–that’s nearly five times as many codes to go through! That’s one reason the details you document in the patient’s medical record are so important
Your billing team will now prepare a medical claim based on the codes applied to the visit. That’s why using the appropriate codes is so important–an incorrect code could alter the charges dramatically. And even though the codes are standard, the fees are not.
Ensure all fees are listed along with the appropriate codes for the visit. By having a clear itemization of medical services, you’ll reduce errors and streamline the process. Any mistakes here could lead to denial of claims and non-payment or reimbursement from the insurer. It can also affect how much your patient may have to pay out of pocket.
Review, File Claims
Once reviewed for accuracy, the claims are submitted for reimbursement. This can be done electronically and usually goes through a scrubbing phase and yet another review process. Software ensures all the form fields are filled out and corresponding codes and fees make sense.
The claims are then sent to a clearing house for a final inspection. They do one final inspection of basic information (name, active insurance checks, date of birth, etc.) and then reformat the claim for specific payers–not all payers use a standard format.
Insurance Adjudication/Reimbursement Process
This is when the insurance company will process the claim, reviewing for covered services or procedures, and then accept or deny the claims. If there are errors, the claim will be denied, although a detailed explanation and steps to rectify any issues will be included. You can then resubmit the claim.
In some cases, the claim can be denied because the services just aren’t covered by the insurer. This is where all of the work at the start of the process pays off, especially when it comes to the patient’s insurance coverage. Now is a terrible time to realize they don’t have coverage when they thought they did.
Prepare Patient Statement
Assuming everything is accurate, a statement is prepared for your patient. If there is a non-zero balance, the charges should be clearly explained along with benefits they do/do not receive from the insurer. That will let them know why there are charges and for how much. Include payment instructions, due dates, and even ways a patient can appeal charges to their insurer.
Patient Follow Up/Payment
The last step in the process is getting paid by the insurer and the patient. For insurance companies, payments are often automatic when claims are accepted. Patients may pay beforehand for a visit (co-pay) or before the procedure takes place. Others may choose to pay at different times.
Although every step in the process is important, getting paid for your services is what allows you to make money, pay your staff, and keep the lights on. There are certain amounts of time that you must give for your patients to begin payment, but you may be forced to go through collections.
Are you having internal problems with any of the 10 steps in the medical billing process? Consider outsourcing the work to MBA Medical Billing Services. Our staff has decades of experience and will help relieve the stress on your practice and ensure proper coding, billing, and payment.