Medical Billing Payment Process and Claim Cycle

Posted on

The medical billing process consists of some steps. Every step should be completed by the billing specialists in order to make sure that the medical professionals are reimbursed for their services. Sometimes, it takes only a few days to complete. In some cases, the process may take weeks or months. Everything depends on the circumstance.

For those who are looking for the process of medical billing payment, you are on the right page as you will be informed about such thing here. Feel free to check out everything below:

Step 1: Patient Registration

The process of medical billing payment and claim cycle is started by patient registration. It is when the information about the patient is gathered, including the name, the birth name, and the reason for a visit. Not only that, the information about the insurance is also collected. Such information includes the name of the insurance provider and the policy number of the patient that is verified by the medical billers. This is such an important information as it is the one that is used to set up a patient file that will be referred to during the process of medical billing.

Step 2: Financial Responsibility

The second thing that should be done is to determine the financial responsibility for the visit. The statement means checking out the insurance details of the patient in order to find out the kinds of procedures and services to be covered during the visit. In the case when there are procedures or services that will not be covered, the patient should know that they are the ones that will be financially responsible for those costs.

Step 3: Superbill Creation

When the checking process in on the way, the patient will be asked to complete the forms for their file. if it is a return visit, instead of completing the forms for their file, they will be asked to confirm or update the information that is already on the file. Aside from the identification, the other things that will be requested are a valid insurance card and co-payments. After checking out, each medical report from the visit will be turned into a diagnosis and procedure codes. This kind of thing will be done by a medical coder. Then, it is possible for a report called superbill to be compiled from all the information that have been collected so far. Everything will include the provider and clinician information, the demographic information and the medical history of the patient, the information on the procedures and services performed, and the applicable diagnosis and procedure codes.

Step 4: Claims Generation

In the next step, the superbill will be used by the medical biller to prepare a medical claim to the insurance company that has been submitted by the patient. After making the claim, they will check everything and will do it properly to make sure that that claim meets the compliance standards of the payer and HIPPA and they include the standards for medical coding and format.

Step 5: Claims Submission

After making sure that the claim has been properly checked for the accuracy and compliance, the next step is the submission. Usually, the claim will be sent through electronic way to a clearinghouse. For those who have no idea about a clearinghouse, it refers to a third party company that connects the healthcare providers and health insurers. However, there is an exception. The only exception is the volume payers, such as Medicaid, the one that will accept the claims directly form the healthcare providers.

Step 6: Monitor Claim Adjudication

The term adjudication is used to described the process when the medical claims are evaluated by the payers and these payers determine whether they are valid and compliant. It will be decided how much the reimbursement that will be received by the provider. When the process is on the way, there is a possibility of the claim to be accepted, rejected or denied. The one that is accepted will be paid based on the agreement made by the insurers and the provider. The one that is rejected will be corrected as it has some errors and after that the claim will be resubmitted. As for the denied claim, it is the one that the payer refused to reimburse.

Step 7: Patient Statement Preparation

After the process of claiming the claim is done, the patient has to be ready as they will be billed for all the outstanding charges if there are any. In general, the statement includes a complete list of the procedures and services that are provided. Not only that, it also includes the costs, the amount paid by the insurance and the amount due from the patient.

Step 8: Statement Follow Up

The last thing in the medical billing process is to make sure that the bills are all paid. If you are a medical biller, it will be needed for you to follow up with the patients whose bills are delinquent. Go send the accounts to collection agencies if it is needed.

Keep in mind that all the steps mentioned above are not default and it is just a general outline. It means it can be different depending on the medical offices. If you are a client or someone who wants to know about the medical billing payment process and claim cycle, you are suggested to visit the likes of the insurance company to be educated with such thing. Not only that, you might also see the medical biller that you know. If there is no one that you know, there are a lot of them that are available online. do not be shy to contact them and ask them anything that you want to know about the medical billing payment process and claim cycle. If you are the kind of person who tends to forget things easily, do not forget to prepare a piece of paper to take some notes so that you will not forget about the thing,

Leave a Reply

Your email address will not be published.