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The Medical Billing Process in Detail

Updated: Aug 1, 2023

Without adequate structure, medical billing and collections can be a challenging procedure. The medical billing procedure, however, is much simpler to comprehend if it is divided into the following parts.

1. Registration of patients - To verify that new patients are qualified to receive medical services from the provider, they must supply personal and insurance information.

2. Confirming financial obligation - The provider can identify which services the patient is covered for by their insurance plan once the patient has provided the physician with their insurance information. The patient must be notified that they are responsible for paying the entire bill if their insurance won't cover the procedure.

3. Translation of the medical report - After a patient leaves the facility, a medical report that contains all relevant information about the service rendered, including the patient's identity and the treating physician as well as the services rendered, is submitted and translated to a medical code. The document is referred to as a "super bill."

4. Putting together the claim and ensuring compliance - The super bill will be given to the medical biller by the medical coder. It will subsequently be included in a claim form together with the price of the operations. The biller is responsible for checking that the claim complies with both billing compliance requirements and coding and formatting requirements after it has been prepared.

5 .Claim submission - In accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, all claims must be submitted electronically. This only applies to common transactions that fall within HIPAA's regulations, though. Billers are still permitted to submit handwritten claims, although doing so may lead to ineffectiveness and a high rate of mistakes.

6. Monitoring adjudication - After the claim has been received by the payer, it will proceed through the adjudication process, during which the payer will assess the claim to see if it is genuine and compliant and to determine how much of the claim will be reimbursed. The report will be forwarded to the biller after adjudication is complete. The biller will next need to verify that the report's codes correspond to the original claim.

7. Creating patient statements - After the report is received, the patient must be sent a bill.

8. Following up on payments - The last step is to get the bill paid. The biller is responsible for making sure the bill is sent out on schedule and for following up on late payments.

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