MEDICAL
BILLING
What is Medical Billing.?
• Medical billing is the process by which healthcare organizations
submit claims to payers (Insurance) to ensure payment for service
provided to patient by a doctor or healthcare provider.
• Medical billing specialists are also responsible for contacting
insurance companies.
RCM : Revenue Cycle Management
• The process of identifying, collecting, and managing the practice's revenue from payers based on the
services provided.
10 Steps of the Revenue Cycle Management Workflow
• Pre Register Patient
• Establish Financial Responsibility
• Check In Patients
• Assign Medical Codes
• Review Billing Compliance
• Check Out Patient
• Prepare Insurance Claims and submission
• Monitor payer Adjudication
• Generate Patient Statements
• Follow-up Payments and Collections.
Pre Register Patient
• Patient calls to make an appointment.
• Patients insurance information as well as their demographic.
Establish Financial
Responsibility
• It is important to verify whether patient is self paying or has
insurance.
• Need to verify patient deductible, copay, coinsurance.
• Insurance verification is important to understand the patient
eligibility.
• Before provider service to patient need to verify whether insurance
active or not, service covered or not, does service require
authorization or not.
• Insurance Authorization is of three types : Prospective, Concurrent,
Retrospective.
Check In Patients
• HIPAA guidelines need to be followed regarding patient privacy.
• Release of Information : Field 12 – need to be signed by patient
which indicates that there is an authorization on file for the release of
any medical or other information necessary to process/adjudicate the
claim.
• AOB (Assignment of benefits) : Field 13 – Insured or authorized
person signature indicates payment of medical benedits.
Assign Medical Codes
• Superbill : Detailed invoice/receipt outlining services provided by
healthcare provider to its patient.
• Superbill contains common ICD 10 CM Codes, HCPCS codes.
• Medical biller need to verify superbill to ensure all codes are captured
correctly.
Review Billing Compliance
• As patient may have 2-3 insurance, need to verify which is primary
and verify fee schedule.
Check Out Patients
• Collect copay or if any previous balance from patient.
• Inform patients about covered and non-covered services.
• Take signature from patient to release information to insurance.
Prepare Insurance Claims and
Submission
• Medical Biller has to enter medical codes into PMS (Practice
Management System), verify documentation & generate CMS 1500
claim form , & submit generated form through clearing house.
• Clearing house acts as a middle man which carries medical claims
information between healthcare professional & active insurance
providers.
Monitor Payer Adjudication
• Adjudication : The process of reviewing and processing healthcare
claims submitted by healthcare providers to insurance companies,
government programs or other third party payers.
Generate Patient Statements
• After insurance pay their portion , generate patient statements and
send to patients for remaining payment.
Follow-up Payments and
collections
• Need to followup on payments that have not been paid or not
responded.
Front Office Data Collection
• Medical Biller’s Responsibilities :
Registering patient information, Performing insurance verification, pre-
authorization, and referral tasks, Preparing and posting transactions on
day sheets, charge tickets and patient accounts, coding and billing
insurance claims, collecting patient payments and performing collective
activities.
Information collected:
• Verify patient demographics
• Obtain insurance information
• Verify either insurance should pay or patient should pay.
THANK YOU
