Medical Billing Process - Let's Learn How It Works

Mawaiz Khan
22 Apr 2024
Medical Billing Services

In today’s complex world of healthcare, maintaining the medical billing process seems to be the most challenging one.

Imagine one minor mistake can cost you a major financial loss – the biggest nightmare for most healthcare organizations.

You would want to get rid of it. Won't you?

Therefore, healthcare organizations must understand the fundamental aspects of the medical billing company for timely claims submission and payment collection.

This blog will explain the medical billing process and its importance in the healthcare industry. Furthermore,  it will highlight the key elements of the medical billing process step by step.

But before you jump straight into the process, let's first understand what medical billing is!  

Exploring the Importance of Medical Billing in Healthcare System

The importance of medical billing is paramount. It is important to ensure it is done correctly to avoid claims denials and compliance violations. According to the ACA Marketplace plans 2021:

“Nearly 17% of the in-network claims were denied by insurers in 2021.”

The following are some of the key pointers highlighting its significance:

  • Medical billing ensures that healthcare professionals receive the right amount of money for their services, enabling them to maintain financial stability and continue the delivery of quality care.
  • It enhances the patient experience and fosters trust in healthcare organizations. Patients feel more satisfied when they are well-informed and charged correctly for their treatment.
  • Additionally, it provides necessary funds for hospital equipment, and daily operations and contributes to the overall functionality and quality of care.

Now that you are well aware of medical billing and its importance, you must be wondering how medical billing works. 

So let’s take a closer look at the process and its integral elements one by one!  

Unveiling the Key Components of the Medical Billing Process

As we have already mentioned the process of medical billing is a crucial aspect of healthcare administration and consists of multiple steps, the process starts with the patient registration and ends when the healthcare providers receive complete payment for their services.

Patient Registration

The first step of medical billing is to register the patients. It involves collecting and documenting all necessary and personal information of patients including demographics and insurance coverage. It is important to note here that documenting the accurate and correct name, address, date of birth, social security number, and contact information is required for proper patient identification.

Moreover, during this phase, billers verify insurance coverage and check if the services are covered within the insurance plan or not. This step must be error-free to avoid claim denials and payment delays eventually.

Medical Coding

The next step is medical coding in which medical coders assign relevant and standardized codes to certain diagnostic tests and medical procedures using ICD-10, CPT, and HCPCS coding systems. 

This step is essential for accurate billing and provides a universal framework for clear communication with the insurance entities and other stakeholders for claims submission and payment reimbursement processes.

Claims Generation and Submission

After registration, form filling, and medical coding, the next critical step is the generation of claims and their successful submission. This step requires meticulous attention from billers, who must thoroughly document and review information of patients such as names, social security numbers, National Provider Identifiers (NPI), and billing codes that reflect the provided medical services.

Once the claims report is generated, their job doesn’t end here as they need to submit claims and patient data as per the rules and standards of HIPAA compliance. Adherence to HIPAA compliance is essential to maintain the privacy and integrity of patient’s data.

As per the guidelines of the HIPAA Privacy Rule:

“It is required for healthcare providers, healthcare clearinghouses, and health plans who are engaged in electronic transactions to protect the individual’s medical records and personal data collectively referred to as Protected Health Information (PHI).”

Claims Adjudication

Following successful claim submission then comes the next phase of the medical billing process – claims adjudication. In this step, insurance companies monitor and review submitted claims. With a comprehensive review and analysis of the claim, they decide to accept, reject, or deny the claims.

They check and assess every piece of information to be accurate, complete, and authentic. In case of missing information in the claims report, they ask to resubmit it with complete information. Once the review process is done, they decide the due payments and pay accordingly. If the claims are non-compliant and have errors, insurance companies deny them.

However, the good news is you can appeal for the denied claims!

Claims Denial Management 

If the claim is denied, you need to put extra effort into reviewing and identifying the possible reasons in a denial report sent by insurance companies. During this step, the main goal of billing staff is to review the payer’s response and determine which additional or missing information is required for resubmission.

The point of concern is to identify the issues in the claims, take active steps, and rectify the highlighted issues. This comprehensive approach ensures that the resubmitted claim is well-prepared, free from errors, and addresses all concerns raised by payers, increasing the chances of successful reimbursement this time.

Eventually, what do you get after all these hectic steps?

You receive payment for valuable and quality care services you deliver to your patients!

Payment Collection and Follow-Up

The final step of the medical billing process is payment collection. After receiving payment, the billing staff checks for remaining balances such as co-pays, deductibles, or any services that are not covered. The patient pays their portion of the payment not covered by insurance.

In cases where claims are partially paid or denied, billing staff follow up with the insurance companies and keep an eye on the process of reimbursement till the end.

After understanding the process of medical billing, you get to know that it is not a piece of cake as it seems to be at first glance. You need to spend long hours and manual effort to get the job done on time.

Every step is critical and you cannot afford to make an error!

With sheer volumes of medical data in hand it is almost near to impossible to review, document patients’ records, and submit claims in a timely manner. So what is the solution?

Medical billing outsourcing is the answer!

Nowadays, third-party medical billing companies can ease the pain of claims submission and payment retrieval.

Are you looking for efficient medical billing services?

If yes, then fret not we have the right option for you!

Medical Billing Services Offered by Dilijent Systems

Dilijent Systems understands the modern-day needs of healthcare professionals and provides comprehensive service resources that include complete revenue cycle management services, software implementation, personalized training, and custom development.

From the initial step of medical billing to the ultimate step of payment collection, it provides end-to-end support to its customers. The following suite of services ensures a seamless and efficient medical billing process for healthcare professionals:

  • Charge capture and rejection management.
  • Denial management – Appeals and Resolution of disputes
  • Patient billing statements and follow-up
  • Validate patient’s data
  • Assign ICD-10 and CPT codes 
  • Audit the coded chart by the QA team
  • Payment posting
  • Claim submission and resubmission
  • Identify denial causes

Are you curious to know more about what Dilijent Systems has for you?

Are you interested in our services?

Contact Us

Final Thought

The medical billing process cannot be overlooked in this modern digital world. Through this process, healthcare professionals submit claims to insurance companies and charge for their medical services. It is highly significant to be careful at every stage of the process for the financial stability and accountability of healthcare organizations. The process consists of multiple crucial steps.

However, managing massive volumes of digital medical data with limited staff resources is challenging. Therefore, it is advisable to opt for seamless medical billing services to make your entire job easier and automatic with the least chances of errors, and ensure security and successful payment reimbursement.