Revolution is the one constant thing in this world. There are a lot of changes going on with the health service claim policy and to keep up with, electronic medical billing and coding help you to stay on the top of everything.
Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes by using CPT®, ICD-10-CM, and HCPCS Level II classification systems.
Medical codes translate that documentation into standardized codes that tell payers the following information:
- Patient’s diagnosis.
- Medical necessity for treatments, services, or supplies the patient received.
- Treatments, services, and supplies provided to the patient.
- Any unusual circumstances or medical condition that affected those treatments and services.
Medical billing is the process of translating a health care service code into a billing claim. It involves the submission of succeeding claims of patients with health insurance companies to ensure that health care providers receive reimbursement for their health care services.
Medical Billing Process:
Medical Billing process comprises of the following nine steps;
The Medical billing process is initiated when a patient schedules an appointment with the health care provider. The receptionist handles preregistration and provides an appointment schedule. If it is the first visit of the patient, the front office prepares the information for the patient’s visit.
- Confirm financial responsibility:
Financial responsibility describes the information of the receivables of the doctors for their health care services. Once the biller has pertinent information from the patient, that biller can then determine which services are covered according to the patient’s insurance plan.
- Patient check-in:
Patient check-in and check-out are relatively straight-forward front-of-house procedures. The patient would be required to provide his/her official identification including; valid insurance card, the driver’s license or passport and copayments.
- Patient check-out:
The medical report from that patient’s visit is forwarded to the medical coder and as soon as the patient checks out, the medical coder abstracts and translates the information in the report into a valid, usable medical code. These medical codes consist of the demographic information of the patients and this information about the patient’s medical history is called the “superbill.”
- Claims/check compliance:
Medical Billers capture the information from the medical coder and also encounter the payment amount. They won’t refer the full cost to the payer, but rather the amount they expect the payer to pay, as mentioned by the third-party payer’s contract with the patient and the provider.
- Transmit claims:
The claims are advanced to the insurance companies, each with their own set of guidelines for claim submission. Instead of having to format each claim specifically, a biller can simply direct the relevant information to a clearinghouse, which would then handle the burden of reformatting all of the different claims.
- Monitor adjudication:
The payer receives the claims and makes it go through the process called “Adjudication”. In this process, a payer appraises a medical claim and decides whether the claim is compliant and, if so, how much of the claim the payer will reimburse the provider for. At this step it is convicted; whether a claim is accepted, denied, or rejected.
- Generate patient statements
Once, biller receives the information from the payer he/she generates the bill for health care services the patient received from the provider. Once the payer has agreed to pay the provider for a portion of the services on the claim, the remaining amount is passed to the patient. A biller may include an Explanation of Benefits (EOB) with the statement. EOBs can be useful in explaining to patients why certain procedures were covered while others were not.
- Follow up on patient payments and handle collections:
It is the last landmark of the medical billing process. It is done to make sure the bills get well paid, Billers are in charge of mailing out timely, accurate medical bills, and then following up with patients whose bills are delinquent. Once a bill is paid, that information is kept with the patient’s file.
Then, the Medical Coder and biller process a variety of services and claims daily. Medical codes must describe the information of the patient’s encounter with the physician and must be as specific as possible in capturing reimbursement for rendered services. Medical billing services assist in the integration between a health care provider, an insurance company and its system. It optimizes the cash flow and decreases the redundancy and errors in the collection process.
Finally, it is imperative to make clear that since HIPAA was signed into law in 1996, it has evolved to establish a set of laws that give patients specific rights to safeguard their healthcare details and data. Sadly, HIPAA cannot completely eradicate HIPAA violations due to human failings and malicious intent. Even the most secure digital technology cannot consider the possibility that a mistake will occur. This page gives you an idea of what else you need to be on the lookout for in your organization, as far as HIPAA compliance is concerned.