Understanding Medical Billing: A Vital

Process for Healthcare Providers

 What is Medical Billing and why it matters to healthcare providers
 Overview of the complete billing process
 Key steps to ensure timely and accurate reimbursements
 Common challenges in billing and their solutions
 Strategies for denial resolution and revenue maximization
Introduction:
 What is Medical Billing?
A process where healthcare providers submit claims to insurance companies to
receive payment for services rendered.
 Importance of Medical Billing in Healthcare
❑ Ensures providers are compensated for their services
❑ Helps maintain smooth financial operations in healthcare
 Objectives of the Presentation
❑ Explain the basics of medical billing
❑ Cover the end-to-end process
❑ Discuss billing techniques and tips
Overview of Medical Billing Process:
1. Pre-Billing Activities:
This stage involves preparing and gathering the necessary information before
submitting claims.
It includes:
• Patient Registration: Collecting patient demographics, insurance details, and
verifying coverage.
• Insurance Verification: Confirming that the patient’s insurance is active and
determining the services it covers.
• Authorization: Obtaining pre-approvals (if require) for specific services to ensure
reimbursement.
2. Claims Generation:
The process of creating claims involves translating medical services into
standardized codes for insurance processing:
• Charge Entry: Documenting all services provided during a patient visit.
• Medical Coding: Using standardized codes (ICD-10, CPT, HCPCS) to describe
diagnoses, treatments, and procedures.
• Claim Creation: Assembling all relevant information into a claim format
(electronic or paper).

 Softwares where claims create:

There are multiple software from where we create claims by entering necessary
details. Some of software names are Office Ally, Athena, AdvancedMD,
eClinicalWorks, Epic etc.
3. Claims Submission:
Once claims are prepared, they are submitted to insurance companies:
• Clearinghouses: Intermediaries that review claims for errors before sending
them to payers.
• Direct Submission: Sending claims directly to insurance companies.
• Timelines: Ensuring claims are submitted within payer deadlines to avoid
rejections.

 What are Payer deadlines?

Payer deadline is the time frame from the date of service provided to the patient
to submit the claim to insurance.
Example of Insurance deadlines:
1-Medicare (365 Days from Date of Service)
2-United Healthcare (120 days from Date of Service)
3-Cigna Healthcare (90 days from Date of Service)
4. Payment Posting:
This stage involves recording payments from insurance companies and patients:
• Explanation of Benefits (EOB): Reviewing the EOB to understand how much
the insurer paid and what the patient owes.
• Adjustments: Recording deductions like contracted adjustments.
• Reconciliation: Ensuring all payments match the claims submitted and
identifying underpayments.
5. Denial Management:
Addressing claims denied by insurance companies to recover payment:
• Identifying Reasons for Denials: Common reasons include coding errors,
missing information, or lack of authorization.
What is Denial?
Refusal of Payment from Insurance.
• Resolution: Correcting errors and resubmitting claims promptly.
• Appeals: If claims are unfairly denied, appealing with proper documentation to
recover payments.
6. Reporting and Analysis:
Evaluating the performance of the billing process to make improvements:
• Key Metrics: Monitoring indicators like claim acceptance rate, days in AR, and
denial rate.
• Data-Driven Decisions: Using reports to identify bottlenecks and optimize
workflows.
• Trend Analysis: Identifying recurring issues with specific payers or processes
and taking corrective actions.
Challenges in Medical Billing
 Compliance Challenges:
Staying updated with changing regulations.
 Insurance Policies:
Handling different payer requirements.
 Patient Communication:
Educating patients about their financial responsibility.
Tips for Medical Billing Success
 Stay Updated with Changes:
Regular training in coding and billing updates.
 Be Proactive:
Follow up on unpaid claims promptly
 Build Strong Payer Relationships:
Communication with insurance companies for smoother processes.
Case Study: Transforming AR Management
for Better Revenue
 The Challenge:
Healthcare providers often face inefficiencies in Accounts Receivable (AR)
management, leading to delayed payments and revenue leakage.
• Our some practices struggled with:
High AR days
Denial rates above industry standards
Lack of visibility into billing performance
 Our Approach:
EliteRush’s Strategies:
• Conducted a comprehensive AR audit to identify bottlenecks.
• Implemented a tailored AR management system to streamline workflows.
• Trained staff on best practices for claim submission and follow-ups.
• Leveraged advanced analytics to track and improve performance
Examples:
Key Actions Taken

 Steps to Transformation:
• Claims Optimization: Improved coding accuracy and reduced errors.
• Denial Management: Addressed root causes of denials and implemented
corrective measures.
• Follow-Up Process: Established a proactive system for tracking unpaid claims.
• Reporting & Transparency: Provided real-time dashboards for performance
monitoring.
Why Choose EliteRush?

 Our Expertise:
• Proven track record across multiple specialties.
• Customized solutions tailored to your practice’s needs.
• Commitment to transparency, accuracy, and efficiency.
 Thank You!

EliteRush LLC – Your Partner in Revenue Cycle Excellence