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MEDICAL BILLING PROCESS

Allam. Harika, III/IV B. Pharmacy

CHEBROLU HANUMAIAH INSTITUTE OF PHARMACEUTICAL SCIENCES

UNDER THE GUIDANCE OF Dr. A. CHAKRAVARTHY, (ASSISTANT PROFESSOR)

MEDICAL BILLING, IT MEANS:

Medical billing is the process of creating healthcare claims to submit to insurance companies to get payment for medical services provided by providers and provider organisations. The medical biller converts a healthcare service into a billing claim and then tracks the claim to make sure the organisation is paid for the work the provider did. For the doctor’s office or healthcare facility, a skilled medical biller can maximise revenue performance.

THE METHOD OF MEDICAL BILLING:

Although there are many steps in the medical billing cycle that can take a few days to several months, the top priorities are accurate billing and prompt follow-up. The majority of states mandate that insurance companies settle claims in 30 or 45 days. On the other hand, payers impose claim submission deadlines that, if missed, void coverage. Without the chance to appeal, the late claim is rejected, and the organization is not entitled to compensation.

Medical billing was largely done on paper for many years. However, it is now possible to manage a lot of claims effectively thanks to the development of medical practice management software, also known as health information systems. In order to serve this incredibly profitable sector of the market, many software companies have emerged. Many businesses also provide full portal solutions via their own web interfaces, negating the expense of separately licensed software packages.

A certification credential to reflect professional status may be obtained by medical office staff members from a variety of institutions that offer a range of specialized education.

The diagnosis and procedure codes are assigned after the doctor examines the patient. These codes aid the insurance provider in determining the services’ coverage and medical necessity. The medical biller will send the claim to the insurance provider once the procedure and diagnosis codes have been established (payer). This is typically accomplished electronically by formatting the claim as an ANSI 837 file and submitting it directly or through a clearinghouse to the payer using Electronic Data Interchange. In the past, claims for professional (non-hospital) services were submitted through a paper form to the Centres for Medicare and Medicaid Services. Paper forms that are filled out manually or automatically using OCR software are used to send some medical claims to payers.

Medical claims examiners or medical claims adjusters typically process the claims on behalf of the insurance company (payer). For claims with higher dollar amounts, the insurance provider assigns medical directors to review the documentation and determine whether the claims are legitimate enough to be paid based on criteria (procedure) for patient eligibility, provider credentials, and medical necessity. A portion of the billed services are paid back for approved claims. The healthcare provider and the insurance provider have already agreed on these prices. Claims that are unsuccessful are rejected or denied, and notice is sent to the provider. Explanation of Benefits (EOB) or Electronic Remittance Advice are the most common forms in which denied or rejected claims are returned to providers. To ascertain the patient’s benefit coverage for the medical services, specific utilization management strategies are implemented.

In the event that the claim is denied, the provider compares the rejected claim to the original, makes the necessary corrections, and then resubmits the claim. Until a claim is fully reimbursed or the provider concedes and accepts a partial payment, this back-and-forth between claims and denials may be repeated several times.

Despite the fact that the terms “denied” and “rejected” are frequently used interchangeably, there is a difference between the two. A claim that has been processed and determined to be unpayable by the insurer is referred to as a denied claim. Usually, a denied claim can be changed or appealed for reconsideration. Insurance companies are required to explain their denial of your claim and provide information on how you can appeal their decision. [2] a negative claim is a claim that the insurer has not processed because the information it received contained a serious error. Inaccurate personal information (such as a name and identification number that don’t match) or mistakes in the information provided are frequent reasons for a claim to be rejected (i.e.: truncated procedure code, invalid diagnosis codes, etc.) A rejected claim cannot be appealed because it has not yet been processed. Instead, it is necessary to investigate, amend, and resubmit rejected claims.

To guarantee that medical professionals are paid for their services, billing specialists must complete a series of steps known as the medical billing process. It may take just a few days to finish, or it may take weeks or months, depending on the circumstances. The workflow for medical billing can vary slightly between medical offices, but here is a general description of it.

STEPS FOR MEDICAL BILLING:

• Registration of Patients

Any flow chart for medical billing begins with patient registration. This is the gathering of a patient’s name, birthdate, and visitation purpose, along with other basic demographic data. The name of the insurance company and the patient’s policy number are gathered, and medical billers then confirm this information. With the help of this data, a patient file will be created and used throughout the medical billing procedure.

• Fiscal accountability

Finding out who will be responsible for paying for the visit is the second step in the procedure. This entails reviewing the patient’s insurance information to determine which procedures and services that will be provided during the visit are covered. The patient is informed that they will be responsible for any costs associated with procedures or services that are not covered.

• Superbill Development

The patient will be required to fill out paperwork for their file at check-in, or if it’s a return visit, to verify or update information already on file. A valid insurance card will be required, and identification and co-payments will be taken. After the patient leaves, a medical coder converts the visit’s medical reports into diagnosis and procedure codes. The information gathered up until that point could then be combined to create a report known as a “superbill.” It will contain information on the provider and clinician, the patient’s demographics and medical background, details on the procedures and services rendered, and the relevant diagnosis and procedure codes.

• Generation of Claims

After that, the medical biller will use the superbill to create a medical claim that will be sent to the patient’s insurance provider. Once the claim has been made, the biller must carefully review it to ensure that it complies with payer and HIPPA compliance requirements, including those for medical coding and format.

• Submitting Claims

The claim is submitted after it has been reviewed for accuracy and compliance. A clearinghouse, a third-party business that serves as a liaison between healthcare providers and health insurers, will typically receive the claim electronically. High-volume payers that accept claims directly from healthcare providers, like Medicaid, are the exception to this rule.

• Track Claim Resolution

The process by which payers assess medical claims to decide whether they are legitimate and compliant and, if so, what amount of reimbursement the provider will get, is known as adjudication. The claim may be accepted, rejected, or denied during this process. According to the insurance company’s agreements with the provider, a claim that is accepted will be paid. A claim that needs to be amended and resubmitted is one that has been rejected. A denied claim is one for which the payer declines to make payment.

• Preparing patient statement

The patient is billed for any unpaid balance after the claim has been processed. The statement typically includes a thorough list of the procedures and services rendered, their costs, the sums paid by insurance, and the sums the patient is responsible for.

• Reaction to a Statement

Making sure bills are paid is the last step in the medical billing procedure. Medical billers are required to follow up with late payers and, if necessary, refer accounts to collections firms.

ADVANTAGES

• An authority on the subject:

Errors can occur because, at many facilities, the task of billing and claims is a full-time job that is expected to be accomplished in part-time hours. By entrusting a specialized agency with your medical billing needs, you can reduce or even completely eliminate your time restrictions and the risk of filing claims erroneously.

• Increased effectiveness:

Imagine how much more productive your office would be if the full-time job of billing and claims processing were mainly automated and the staff hours used on this project were added back to your pool of available hours if you nodded in agreement when we claimed it was a full-time job. Even better, using a medical billing service means your vendor is now in charge of any rejected claims or collections that formerly gave you so many issues. As a result, you can go forward with completing new job without having to put in as many labor hours dealing with the past.

• Charging the highest amount:

Your medical billing service should assist you in increasing your revenue by invoicing each service at the highest billable level in addition to decreasing the amount of time you spend at work on billing and claims. Because the system’s self-coding software is expressly designed to identify revenue opportunities that may be overlooked when filing manually, your service may really have the potential to quickly pay for itself.

• Simple to use:

It shouldn’t be necessary for you to undergo a specific training program merely to comprehend the system in order to optimize your medical billing services. Instead, you should anticipate that your system will be put into place in less than a day and that your team will have no trouble utilizing it after receiving relatively little training. And you can count on your vendor to be available to respond to any questions your team might have.

• No capital outlay:

Only a web-based solution should be used for your medical billing service. This enables you to take use of its benefits with the assurance that you don’t need to worry about having enough room or money to cover the system’s operating costs.

• Cutting-edge technologies:

Technology is the industry where change happens even more swiftly than it does in the healthcare industry. Wouldn’t it be good if your bills could be removed from the picture given how frequently you are inundated with information about the most recent gadget, procedure, or platform that can assist your facility? When a vendor partners with medical billing services, it is their responsibility to make sure the technology being utilized to process your claims is always state-of-the-art. By doing this, you can achieve your goals without having to worry about investing money or dealing with hassles. Your vendor should also be able to provide you with a technological solution that smoothly interfaces with the current system at your facility so you can combine your Electronic Medical Records (EMR), Medical Practice Management (MPM), claims, and other related systems.

• Return to your area of expertise:

Don’t do it because you went into medicine to help people, not to waste time worrying about claims and billing. Trust a company to handle your medical billing needs so you can go back to what you do best—treat patients—by focusing on this difficulty. With your work and the outcomes of your claims, you’ll be happier.

Therefore procedures, medical diagnoses, medical services, and equipment are all converted into medical alphanumeric codes through a process known as medical coding. The accuracy and income of the business are greatly affected by reducing and managing medical coding and billing errors.

REFERENCES:

1. National coalition on Health Care, Facts on the Cost of Health Care . WWW.nchc.org/cost.html
2. Compliance Program Guidance for Individual and Small Group Physician Practices. Federal Register, Vol. 65,no.113,or http://oig.hhs.gov/authorities/docs/cpgphysiciandraft.pdf.
3. Ward WJ. Health Care Budgeting & Financial Management .2^nd Ed. AUPHA Press/Health Administration Press, Chicago, Illinois,1996.