The 10 Steps of Medical Billing

Healthcare providers are responsible for treating patients with the utmost consideration and care. While thoughtful treatment is critical to a doctor’s success, a private practice must also focus on revenue cycle management to continue to provide quality medical services.

The medical billing process can be broken down into 10 steps, beginning with the patient’s visit and ending with the receipt of payment. Along the way, you’ll need to communicate with your patient, your team, and your patient’s insurer. While the process can be quite complicated, follow the steps, and you’ll be poised to see it through as smoothly as possible.

1. Patient Registration

Registration is a part of every patient’s visit—whether it’s their first time in your office, or their fiftieth. A first visit should always include an examination of the patient’s complete medical history and demographic for your records.

For subsequent visits, it’s always important to check whether any information you have for them may be out of date. That includes not only their insurance status but their address, phone number, name, etc. It’s crucial to make any updates necessary at every visit in order to ensure there are no errors in treatment or billing.

2. Verify Insurance

This is an important part of the registration process. Always ensure you have your patient’s current insurance information and that your records are accurate. There may also be a secondary that should be billed, for example, if your patient is in because of a work-related accident.

This step ensures that your patient’s visit will be covered, while allowing you the opportunity to indicate any payment that may be required from them directly. It is far better to acknowledge out-of-pocket payments in advance, rather than surprise your patient after their visit.

3. Document the Treatment You Provide

Write down everything your patient shares about their condition, and everything you find through examination. Either take detailed notes, or record the meeting for later transcription. Be sure to make clear the reason for your patient’s visit, and note any and all diagnoses, prescriptions, etc. This serves two purposes: 1) To contribute to your patient’s medical history and 2) To help you code the services provided for insurance billing.

This can be streamlined by using your EMR system effectively and efficiently. Whether you use eClinicalWorks, TrakNet/ModMed, NextGen, or another records system, ensuring everyone records patient information accurately in the system will make the next step much more manageable. 

4. Relay Documentation to Billing

The record of treatment you provide your patient—known as a “medical script”—should now be sent to your billing team, who translates it into the appropriate codes to ensure prompt payment by the insurer. Any mistakes made here can be costly, resulting in a denied or delayed claim, so be sure your medical script is free of errors, and your coding team is tip-top and up-to-date on the current codes.

5. Apply CPT Codes

Translating the medical script into code can be a laborious process, with some potential pitfalls along the way. CPT or HCPCS codes must be accurately selected, and bundled appropriately with a primary procedure or billed separately.

Diagnoses are coded according to around 68,000 ICD-10 codes. Details are key here, and you’ll be thankful for the careful medical script you’ve created when you wade through all these codes to find the appropriate one(s).

6. Enter Charges to Insurance

Now you prepare an insurance claim based on the codes. This is why coding is so crucial: charges differ across codes, so a miscode could result in a dramatically different claim. This can raise eyebrows at an insurance company, who may become suspicious of apparent coding errors.

List fees along with codes for all services applied during the patient’s visit. Clear itemization helps reduce errors, speed up the process, as well as help minimize the amount your patient will be responsible for paying directly.

7. Review and File the Claim

An electronic claim review is recommended. Computer software can quickly “scrub” the claim to ensure that all fields are filled out and can even recognize red flags in terms of unusually bundled codes or fees that appear inappropriate for the code they are matched with.

Claims then go to a clearing house, where they are inspected one last time. Here, they’ll check the patient’s basic information and then reformat the claim for the particular payer it is headed for. Unfortunately, there is no standard format in which all insurance companies accept claims.

8. Adjudication/Reimbursement

Now the insurance company processes the claim, again reviewing information and making sure that all billed services are ones they are bound to cover according to their contract with you. At this time, they accept or deny the claim. Denial can result from simple errors, but in this case, they will also explain their judgment and the steps you’ll need to take to set things right. Still, this is costly in terms of putting your staff back to work on a claim that appeared finished, as well as the delay in payment.

9. Create a Statement for Your Patient

Your patient’s statement may reflect a balance of zero or an amount they are expected to pay in addition to what their insurance has covered. It’s important to clearly explain any charges for which your patient is responsible, and hopefully, you have already explained to them that they may need to pay for some services out-of-pocket before you provide those services. It’s a good idea to include payment due dates, instructions, and even the procedures for appealing any claims that have been denied by their insurer. If you offer a payment plan, instructions for setting that up are also important.

10. Follow Up / Payment

The final step is receiving payment, both from the insurer and the patient. This can happen quickly and painlessly, or it may take some time, depending on any errors that were made during the previous steps.

A good medical billing services company, such as Healthcare Revenue Group, can take this work off your table, allowing you to focus on what’s important to you. We can handle all aspects of medical billing, with a special focus on podiatry medical billing and audiology billing. We’ll design a process for your practice that makes it easy to capture all the right data throughout your patient’s experience with you, and we’ll minimize denied claims while at the same time working to rectify any that do occur. We’ll even go to work to help renegotiate your contracts with insurers and even suggest new insurance providers with whom you would be beneficial to contract.

Contact Healthcare Revenue Group to find out more about how we can help streamline your revenue cycle and grow your practice at a pace that is comfortable for you!