Provider Enrollment

How does medical insurance billing work?

Bills from your physician are sent electronically to a data warehouse that submits the claims to the individual insurance companies for processing. Keep in mind that from the start of this process through to the finish your claim ill go through over 10,000 electronic edits between the warehouse edits and the insurance company edits. Not all edits are fatal to the claim, but most are. Thank you computers!

If your claims are denied, you need to become familiar with the reason codes used on your claims identifying at what point your claim failed a fatal edit.

Common reason codes:

  1. This service is not covered for this diagnosis/condition.
  2. This service is not covered when performed in this place of service
  3. This service is not covered by this plan.
  4. The patient was not covered on this date of service.
  5. This service is not covered when performed by this type of provider.
  6. This service is not paid separately.
  7. This is not a plan benefit.
  8. The payment for this service is included in the global payment of another service.

All insurance companies have their own language for there denial reason codes. When you find out why your claims are being denied, you can then try to find a way to address your insurance companies denials. Different reasons, different methods.

The medical billing process is a series of steps completed by billing specialists to ensure that medical professionals are reimbursed for their services. Depending upon the circumstances, it can take a matter of days to complete, or may stretch over several weeks or months. While the process may differ slightly between medical offices, here is a general outline of a medical billing workflow.

Patient Registration
Patient registration is the first step on any medical billing flow chart. This is the collection of basic demographic information on a patient, including name, birth date, and the reason for a visit. Insurance information is collected, including the name of the insurance provider and the patient’s policy number, and verified by medical billers. This information is used to set up a patient file that will be referred to during the medical billing process.

Financial Responsibility
The second step in the process is to determine financial responsibility for the visit. This means looking over the patient’s insurance details to find out which procedures and services to be rendered during the visit are covered. If there are procedures or services that will not be covered, the patient is made aware that they will be financially responsible for those costs.

Superbill Creation
During check-in, the patient will be asked to complete forms for their file, or if it is a return visit, confirm or update information already on file. Identification will be requested, as well as a valid insurance card, and co-payments will be collected. Once the patient checks out, medical reports from the visit are translated into diagnosis and procedure codes by a medical coder. Then, a report called a “superbill” may be compiled from all the information gathered thus far. It will include provider and clinician information, the patient’s demographic information and medical history, information on the procedures and services performed, and the applicable diagnosis and procedure codes.

Claims Generation
The medical biller will then use the superbill to prepare a medical claim to be submitted to the patient’s insurance company. Once the claim is created, the biller must go over it carefully to confirm that it meets payer and HIPPA compliance standards, including standards for medical coding and format.

Claims Submission
Once the claim has been checked for accuracy and compliance, submission is the next step. In most cases, the claim will be electronically transmitted to a clearinghouse, which is a third-party company that acts as a liaison between healthcare providers and health insurers. The exception to this rule are high-volume payers, such as Medicaid, who will accept claims directly from healthcare providers.

Monitor Claim Adjudication
Adjudication is the process by which payers evaluate medical claims and determine whether they are valid and compliant, and if so, the amount of reimbursement the provider will receive. During this process, the claim may be accepted, rejected or denied. An accepted claim will be paid according to the insurers agreements with the provider. A rejected claim is one that has errors that must be corrected and the claim resubmitted. A denied claim is one that the payer refuses to reimburse.

Patient Statement Preparation
Once the claim has been processed, the patient is billed for any outstanding charges. The statement generally includes a detailed list of the procedures and services provided, their costs, the amount paid by insurance and the amount due from the patient.

Statement Follow-Up
The last step in the medical billing process is to make sure bills are paid. Medical billers must follow up with patients whose bills are delinquent, and, when necessary, send accounts to collection agencies.

Outsourcing medical billing company will do the following in the chronological order – register the patient, verify their insurance, review the case according to the ICD-10 Code, prepare and then submit their claim, monitor the patient’s payment, follow up on the insurance front, collect payouts, post the payment to your practice and then follow up with the patient for feedback. The cycle continues as new patients register and old patients return for follow up treatment. The companies that offer medical billing services must perform these functions – generate and submit insurance claims, insurance carrier follow-up, posting and processing the payment, providing both invoice and support to the patients, pursue denied insurance claims, credentialing, medical coding, insurance eligibility verification, etc, etc

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