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MEDICAL BILLING PROCESS

Author: Sadam Manasa Leela*¹

Abstract:

It can be exceedingly difficult to manage any practice’s medical billing duties in the modern, complicated healthcare sector. It is at this point that outsourcing medical billing is a practical choice. Making the switch to a paperless medical practice is crucial. All types of medical records are converted to digital format through the abstraction process.

Introduction:

Medical billing is the procedure through which healthcare professionals draught and submit claims to payers insurance companies to get payment for services rendered to patients. Many claims that are denied can be amended and challenged, including those that are refused due to incomplete or inaccurate data, duplicate or late submissions, incorrect or obsolete CPT or ICD-10 codes, a lack of supporting paperwork or prior authorization, among other reasons.

Despite the fact that medical billing operations were formerly carried out using paper-based techniques and handwritten or typewritten papers, the emergence of numerous technologies in the healthcare sector has converted it to an electronic process. This has eliminated human and administrative errors and saved time and money. [1]

Medical Billing Processes:

Medical billing is simply a process with eight straightforward steps, despite its size and apparent complexity. [2] These steps include;

1. Registering Patients: A patient effectively preregisters for their doctor’s visit when they phone to make an appointment with a healthcare professional. If the patient has previously seen the practitioner, their information is already on file, therefore all they need to do is give their visit’s purpose. In order to confirm that a patient is qualified to receive services from the provider, a new patient must supply the provider with personal and insurance information.
2. Confirm Financial Responsibility: Financial accountability outlines who owes what for a specific doctor’s appointment. Once the biller obtains the necessary information from the patient, it can next identify whether services are covered by the patient’s insurance policy. Because insurance coverage varies greatly between organisations, people, and plans, the biller must verify each patient’s coverage in order to assign the bill accurately. Certain services or prescription drugs are not covered by all insurance policies. The biller must inform the patient that they will pay the entire balance if the procedure or service is not covered by their insurance.
3. Patient check – In patient Check – Out Front-of-house activities like checking in and out patients are rather simple. Depending on whether it is the patient’s first visit to the provider, they may be asked to fill out some paperwork, or if it is not, they may be asked to verify the information the doctor already has on file. In addition to a valid insurance card, the patient will be needed to present some form of government identification, such as a driver’s license or passport. Copayments will also be collected by the provider’s office when a patient checks in or out. After the patient leaves, the medical report from their visit is forwarded to the medical coder, who abstracts and converts the data into precise, usable medical code. The “super bill” is a report that also contains the patient’s demographic data and details about their medical background. Detailed information regarding the medical services rendered is included on the super bill. This comprises the names of the patient, the doctor, the provider, the procedures done, the codes for the diagnosis and procedure, and other crucial medical details. The claim must be created using this information. The super bill is then delivered to the medical biller after completion, usually through a piece of software.
4. Prepare claims/check claims: The medical biller receives the super bill from the medical coder and enters it into the appropriate practise management or billing software, or into a paper claim form. The cost of the procedures will also be included by Billers in the claim. They will send the payer only the amount specified in the payer’s contract with the patient and the provider, not the entire cost. The biller is in charge of making sure that the medical claim complies with all regulations regarding coding and format after the claim has been created. Although claims may have different formats, they typically contain the same fundamental details. Each claim includes information about the patient, including their demographics and medical history, as well as the procedures carried out (in CPT or HCPCS codes). Each of these operations is accompanied by a diagnosis code (an ICD number) that indicates the medical necessity. There is also a price stated for certain operations.
5. Transmit claims: All health entities covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required to file their claims electronically, with few exceptions. HIPAA covers the majority of payers, clearinghouses, and providers. A clearinghouse is a third-party corporation or organisation that accepts claims from billers, reformats them, and then sends them to payers. Some payers have highly precise formats that claims must be submitted in. By gathering the data required to make a claim and then putting it in the proper form, clearinghouses lessen the burden on medical billers. [3]
6. Monitor Adjudication: When a claim is submitted to a payer, it goes through an adjudication process. In adjudication, a payer assesses a medical claim, determines whether it is legitimate/ compliant, and, if so, determines how much of the claim the payer will pay the provider. A claim may be approved, disapproved, or rejected at this point. Following adjudication, the payer will provide a report to the provider or biller outlining the parts of the claim they are willing to pay for and why. This report will provide a list of the operations the payer will pay for along with the budget the payer has set aside for each procedure. This is frequently different from the costs specified in the initial claim. The payer and provider typically have a contract that details the costs and rates of payment for certain procedures. The report will also include justifications for why the payer won’t pay for a specific procedure.
7. General Patient Statements: The biller must now create the patient statement after receiving the payer’s report. The statement is the invoice for the procedure or procedures the patient gets from the provider. The leftover sum is transferred to the patient after the payer has agreed to pay the provider for a portion of the claimed services. An Explanation of Benefits (EOB) may be attached to the statement by the biller in certain circumstances. An EOB details the benefits and consequent coverage that a patient is entitled to under their plan. EOBs can be helpful in explaining to patients why some operations were covered while others weren’t.
8. Follow up on patients payments and handle collections: Assuring that the bills are, in fact, paid is the last stage of the billing process. Billers are in responsible of sending out accurate, on-time medical bills and contacting patients whose payments are past due. Following payment, a bill’s details are kept in the patient’s file. It is the biller’s job to make sure the provider is fairly compensated for their services if the patient is late with their payments or does not pay the whole amount. This can entail getting in touch with the patient directly, delivering follow-up bills, or, in the worst-case scenario, hiring a collection agency.

             (  Fig 1: End-to-End Medical Billing Services )

Benefits of Medical Billing Software:

It is the 21st century, and writing documents with hands can be difficult. Using software instead of managing the details by hand with paper documents speeds up the entire process, and it is much easier looking and manage the documents. [5]

1. Minimize the paperwork: You can reduce paperwork and associated errors by using electronic billing. Keeping documents safely stored is another benefit. The materials are also available to you 24/7, wherever you are.
2. Claim processing: The billing software makes processing claims very simpler. It is more effective and leaves less space for error. Additionally, submitting claims is quicker. Before they are filed, the software also verifies your claims and claim codes.
3. Easy payment: The billing software offers a variety of payment choices. Patients gain from it as well because they can pay conveniently and easily using credit cards.
4. Reduced Expenses: The cost of medical software is cut in half. Even while it initially appears pricey, doing so will ultimately save your expenditures because you won’t need to pay for as much infrastructure, staff, social security, insurance, and other extras. It helps you avoid all of these extra costs while also saving you money. [6]
5. Billing at the highest rate: Your medical billing solution should enable you to charge each treatment at the highest billable level in addition to lowering the amount of time you spend at work on billing and claims. The system contains self-coding software that is specifically designed to identify revenue opportunities that can be overlooked when filing manually, so your service may actually have a quick payback period.

Fig 2:  Benefits of Medical Billing Outsourcing

Medical Billing Insurance with respect to Insurance Company;

(STAR HEALTH)

On taking star health as a medical insurance company for medical billing. Regardless of even the smallest surgery or therapy, in-patient admissions in India end up being costly. When purchasing your health insurance, make sure you fully comprehend the terms of the policy. In this hectic environment, be ready to deal with health difficulties. Therefore, it is always advisable to take safeguards that would be useful in case of medical emergencies. According to experts, both forms of paying for hospitalization costs are acceptable, and having health insurance is a need. It is obvious that handling medical emergencies would be best done either cashless or through reimbursement.

 Cashless Facility:

When hospitalization is cashless, the health insurance company (the insurer) pays the network hospital directly for the insured person’s (the policyholder’s) medical care in accordance with the terms of the policy.

The hospital receives payment directly from the insurance provider for all emergency and planned hospitalizations at affiliated hospitals.

1. a) planned hospitalization can be informed anywhere from seven to ten days in advance.
2. b) Notification of Emergency Hospitalization within 24 hours after Hospitalization

The necessary paperwork for the cashless request will be sent to Star via the hospital’s insurance desk’s Hospital Portal.

The insurance will pay the hospital’s cost after notifying that your request has been approved.

Reimbursement Claim;

A reimbursement claim is paying the hospital cost out-of-pocket before requesting reimbursement from the insurance provider.

The patient after the completion of treatment in the hospital. Patients or the representatives take the medical bills to the insurance company and the company after thoroughly checking the bills they ask the patient to pay the rest of the amount inspite of how much the hospital would bare according to the insurance policy of the patient. 

Conclusion:

The phase of the doctor-patient relationship that is most crucial is the medical billing process. It guarantees that all expenses will be paid. Additionally, it aids in keeping track of your receivables and payables. The type of income gathered determines how much money successful medical billers or doctors make. This is only feasible if the medical billing procedure runs well. Only if it is flawless will the medical billing procedure be successful. This means that each stage in the procedure needs to be completed with adequate documentation and customer care.

References:

1. World Health Organization. The world health report: health systems financing: the path to universal coverage. 2010. Available at http://www.who.int/whr/2010/en/.
2. Suman SOOD v Regina 2006 NSWCCA 114. New South Wales, Court of Criminal Appeal.
3. Centers for Medicare & Medicaid Services. The False Claims Act. https://downloads.cms.gov/cmsgov/archiveddownloads/SMDL/downloads/SMD032207Att2.pdf.
4. Alok Prasad, EMR, EHR and Revenue cycle blog for Physicians, Revenue XL blog, Jan 23, 2022.
5. e Claim Solution – An Idiosyncratic Healthcare Service Providers 
6. Matthews MJ, et al. In: Stat Pearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. PMID: 25298311.
7. Star  Health support@starhealth.in