At EMBER Medical Billing, we often get asked about our role as a full-service medical billing company. Many wonder what exactly medical billing entails. In this article, we provide a general overview of the medical billing process for those interested in understanding its components.

What is Medical Billing?

Medical billing is the active management of claims submission and follow-up with health insurance companies to obtain payment for medical services provided to patients. It involves translating healthcare procedures, treatments, and services into standardized codes and submitting the necessary documentation for reimbursement.

Here’s a step-by-step breakdown of the process:

Patient Registration

The billing process commences when a patient visits a healthcare provider and provides personal and insurance information, which is then recorded and stored in the patient’s medical records.

Insurance Verification

Staff verifies the patient’s insurance coverage, including eligibility, benefits, and any per-authorization requirements for specific procedures or treatments.

Coding

Healthcare procedures, diagnoses, and services provided to the patient are accurately translated into standardized codes using medical coding systems such as the Current Procedural Terminology (CPT) and the International Classification of Diseases (ICD). These codes play a crucial role in reimbursement.

Claims Submission

The coded information, along with relevant documentation like medical records, is compiled into a claim form. This claim is then submitted either electronically or in paper format to the patient’s insurance company, containing essential details about the patient, the healthcare provider, the services rendered, and associated costs.

Adjudication

Once the insurance company receives the claim, they perform an adjudication process. This involves reviewing the claim for accuracy, completeness, and compliance with their policies. The insurance company determines the amount they will reimburse the healthcare provider based on the patient’s insurance coverage.

Payment Processing

Following adjudication, the insurance company sends a payment or explanation of benefits (EOB) to the healthcare provider. The EOB outlines the covered services, any deductibles or co-payments, and the reimbursement amount. The healthcare provider then reconciles the payment with the services provided.

Patient Billing

If there are any outstanding amounts after insurance reimbursement, the healthcare provider generates a patient bill. This bill is sent to the patient, providing details of the balance due and instructions for payment. The patient is responsible for directly paying the remaining amount to the healthcare provider.

Follow-up and Appeals

In cases where a claim is denied or underpaid, the medical billing staff initiates follow-up with the insurance company to resolve any discrepancies. They may provide additional documentation or file an appeal to request reconsideration of the claim.

Accounting and Reporting

Our services encompass maintaining accurate financial records, tracking payments, and generating reports for the healthcare provider. These records aid in monitoring revenue, analyzing reimbursement trends, and ensuring compliance with regulations.

Medical billing plays a critical role in the healthcare system, ensuring healthcare providers receive timely and accurate payment for their services while optimizing patients’ insurance benefits. From patient registration to reimbursement, the medical billing process involves expertise in coding, claims submission, payment reconciliation, and more. By understanding this process, providers can appreciate the importance of professional medical billing services in streamlining operations and maximizing revenue.