The medical billing process is a complex, complicated, jargon-heavy, challenging task that requires a meticulous mind and approach — oftentimes even nerves of steel. It is not only hard but a bit mind-numbing; full of red tape, bureaucratic gymnastics, continued deficiencies, reversals, and even audits. In this article, we’re going to guide you - step by step - as to how this process normally looks like. What are the steps and procedures of medical billing and how to, perhaps, improve them.
What is the medical billing process?
Medical billing is the way most physicians get paid. Is how they translate all their work, all their services, all their healthcare action towards a patient into profit. It is how they transform all their records into transcribed claims and invoices that they can then get paid for by the insurance company (such as AHCIP) of that individual they helped out.
The process is complex, it’s not just a typed invoice, but a transcribed record that has to fulfill 10 steps before being successful.
Why is it a complex and complicated process?
The process of medical billing is incredibly complex because it starts right away, from the very first moment the patient makes contact with you — and ends when the insurance provider, after adjudication, deposits their reimbursement into your bank account. Every step is mired in different sub-steps, for example, the claim submission process in medical billing. Each step has its own level of complexity.
Steps of the Medical Billing Process
Let’s take a look at each of these steps, what they entail when they start, and the many traps and pitfalls they have. First, it’s important to note that every practitioner, and their team, have their own methodology. In most cases, they resemble those of their peers, but in some instances, they may differ wildly. Why? Everyone believes they have the key ingredient. They have their own set of rules and guideposts that have worked for them and have streamlined their revenue management process. Nevertheless, on average, the process more or less stays the same.
The process, in some form or another closely follows the following steps:
The moment the patient walks into your office, your hospital, your practice he or she needs to be registered. All data is collected. Not just their medical history and issues, but their insurance provider and medical coverage. A record is started on that patient.
In the case of an old patient, one already in the practitioner’s care, their record is updated with new pertinent detail added to their folder. This is a critical step because thanks to that data the medical billing process can begin.
While the patient waits, if they can and it’s not an emergency, your team verifies their data — mainly their insurance. They evaluate that individual’s medical coverage, including if their insurance is still operational.
Each of your interactions with your patient needs to be recorded — either in voice form, video, or written down. Every single procedure, every single encounter you have with that individual must be recorded for insurance purposes. You’ll need to present factual, irrefutable proof of everything you did and how you treated them.
Your recordings, during this stage of the medical billing process, need to be transcribed — and later formatted. All information needs to be verified, wrong data corrected and, ultimately, things that might hurt the claim need to be examined.
The transcribed records, now written down in plain English, now need to be translated. During this stage of the medical billing process, you or your team needs to transform all that is written into medical coding. There are universal medical codes for every procedure, every exam, every prescription. All insurance companies, all medical institutions know of this code and are well-versed in it. If your patient broke their ankle, there is one for that. If you need to prescribe antidepressants, there is a code for that. Thanks to this coding, claims are filed faster and pushed through the system more efficiently.
In this stage, everything is invoiced, cataloged and all charges are entered into the claim/sheet. It is an accurate and precise transcription, one that needs to have every red-cent accounted for otherwise a claim may be denied.
During the Charge submission, the medical billing process starts to inch its way to the goal. This is when your team, or your medical billing service provider, sends everything over in an orderly fashion to the adjudicating entity (i.e. Alberta Health / ACHIP).
For security measures and also to avoid issues by automating most of the process, this is done by way of electronic transmission to an intermediating software service (in Alberta this is called H-LINK). This is a digital/electronic network that Alberta Health uses for all these claims.
In most cases, if an error was made, this is where they start to pop up. Why? The network is incredibly precise and can start to pick up errors in the claim and such.
Some of the errors you might encounter during this stage of the medical billing process are:
- Not filling out mandatory fields.
- Invalid information that clashes with the patient’s records.
- Missing information such as the referring physician.
- A clash between what is an allowable Health Service Claim for the work performed (as determined by an ICD10 code)
This is when you submit the claim.
A/R Calling or Account Receivable is when your staff (or billing agents like ResolvMD) initiates calls to payors like Alberta Health to request the status of a claim. It is a timely follow-up that in many cases, nowadays depending on the digital platform of the instance company, can be automatically scheduled and done through optimized software.
When it comes to the medical billing process one of the most important steps is deficiency management. This is a key factor as it helps determine why a claim is being denied and - depending on the reason - if there are ways not only to redact and edit the claim but improve the medical billing process on your part to reduce denials.
What is the last step in the medical billing process? In most cases, it is you just receiving money into your account! In Alberta, you can reconcile this against your statement of assessment. Sometimes there are clinical payments made with disbursements and overhead adjustments to follow. This can be aided by staff or third-parties as well.
Why follow a proper medical billing cycle process?
These steps help the medical billing process and procedures and give you a platform on how to improve the medical billing process. They allow for your practice to grow by accessing numerous medical claims with no errors and fewer denials. Every company might follow its personal procedure in hindsight, they more or less stay close to the ones described here. Why? Because they give you commercial stability in the market.
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Want to learn more about our billing services and physician insights portal? We would be happy to connect with you!
ResolvMD is an experienced full service medical billing company that empowers physicians to bill more efficiently through data-derived insights and democratized knowledge. We believe you should be as confident and competent in your billing as you are in your practice. Our proprietary Physician Insights Portal harnesses the power of data to deliver customized insights directly to you in real time. No more second guessing or feeling like you don’t have the transparency and accountability that you deserve. Paired with the most modern and secure platform on the market, you can rest easy knowing that we are taking care of all your billing needs while fine tuning your ability to understand best practices and earn what you deserve.