The Process of Medical Billing and Coding

The Process of Medical Billing and Coding

The process of medical billing is very important and complex for a medical association or healthcare provider and is not conducted by a single individual but a team of skilled people, who have the tendency to perform the task accurately. The process of medical coding involves front office administrators like receptionist and the back office staff like the biller and coder. The primary task of medical billing specialist is to

  • Understand responsibility of every individualfor the payment as they may differ from one patient to the other.
    • Evaluate and analyse the insurance coverage and medical charges to prepare the accurate billing forms.
    • Collection of the accurate payments from the insurance plans or the patients.

This process is completely technical and the healthcare providers would need to hire or train the staff that is skilled to perform this process. To understand this, you would need to know the process involved in medical and health insurance billing procedures.

1 – Registering the patient-

A patient would need to do pre-registration for getting the doctor’s appointment. If the patient has already seen the healthcare services providers, the medical billing and coding staff would have their insurance and medical information. The new registered patient might need to provide all this information at the time of booking an appointment.

  1. Analyse financial responsibility-

The financial responsibility refers to who owes what for the visit of a particular doctor. Once the biller or coder gets the information of the patient, they could determine which services are covered under the patient’s insurance plan.

  1. Check-in and check-out-

When the patient arrives at the healthcare institution, they would be asked to complete forma or confirm the recorded information. This step of process would need the patient to provide with identification proves and the provider’s office would also collect co-payment during patient check-in or checkout out.

  1. Check compliance-
    The medical billerwould take the super bill from the medical coder and put it into some form or billing software. The billersare required to include the cost of procedure in the claim.
  2. Transmit claims-
    After compliance, the billerwould then transmitthe claim to the payer. The guidance of HIPAA, all the medical service provider are expected to submit claims electronically.
  3. Adjudication-
    When the claim reaches the payer, they need to evaluatethe medical claim and decide if the claim is valid, how much of claim the payer will reimburse the provider. At this stage, the claim may get accepted or rejected.
  4. Patient’s statement-
    After the billerhas received the report from the payer,statement of the bill is prepared. When the payer has agreed to pay a portion of the service to the provider, the remaining amount gets passed to the patient.
  5. Follow up-
    The last step of the process includes follow-up. This process makes sure that those bills get paid. The billersare in charge of mailing, accurate medical bills and then follow-up with the patients whose bills become delinquent. This is the last and most crucial step for insurance pay for medical billing and coding.

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