How Successful Medical Billing Companies Compile Claims?

Overview

An effective and efficient healthcare system is based on the joint effort of all of its parts, such as healthcare providers or clinicians, the medical equipment, the administrative staff, medical billing companies, and the insurance companies.

A medical practice requires financial support and resources to run. It is so they can compensate their staff and heads, buy new medical equipment, expand their practice to serve more patients, and so on.

All of this can be done with the help of a proficient team that caters to their revenue cycle management.

Revenue Cycle Management

It is the financial management process by which healthcare systems in the USA and the rest of the world track the performance of their claims. Communication with insurance companies is an essential part of this system, which typically third-party vendors like medical billing services are in charge of doing.

A medical practice can be sustained if the revenue management cycle is handled efficiently. A small mistake regarding a patient's details can lead to a massive backlog. It can be an inconvenience for the in-house staff or the outsourcing medical billing company, as they will have to take care of it, along with their already existing duties.

Regardless, it can be easily remedied by letting a medical billing company take care of it.

The Connection Between Medical Billing and RCM

The working of the Revenue Management Cycle is entirely based on how effectively and meticulously patients' information is processed into the system.

It is where the medical outsourcing companies come into play.

They consist of experienced professionals who can read, interpret, record, and track complex medical details. And can note, submit, and take care of follow-ups when it comes to medical claims with insurance companies.

This entire process is quite challenging, which is why trained professionals are the best at handling it.

Steps for Successful Medical Billing

Patient Registration

The first step in medical billing is to take down the patient’s information, such as their gender, address, phone number, etc.

Then come the insurance details, which are things like

• Insurance plan
• Policy Number/ID 
• Name of insurance payer

All of these things have to be carefully recorded, and if required, they can also be updated when the patient becomes a regular visitor to the clinic.

It is because they form the basis of the medical claim that compensates the clinicians for their rendered services.

Nowadays, most practices use advanced medical billing and coding software that only requires them to enter the information once. This way, patients do not have to give their details again and again for each visit. 

Verification of Insurance

Patients are required to check their insurance plan’s eligibility before each visit to the clinic. It is important because the coverage status for their treatment gets updated or can change at any time. Medical billing companies are very particular about this step, so they do not have to invest efforts all over again.

The healthcare provider should ask about this carefully and even double-check the information provided, as it can affect the claim processing and resulting reimbursement.

Keep in mind that insurance status is also a key factor here as only active insurance plans are processed.

Patient-Provider Meeting

After all of the details are taken care of, the patient and the healthcare provider have a meeting, where the patient describes their symptoms, while the provider takes all this into account and suggests appropriate measures and treatments.

Audio or video of the meeting gets recorded as well. It ensures that the proper diagnosis and course of treatment were given, and the correct basis of the claim was stated. The success of medical billing services depends highly on the accuracy of this step. After all, the more accurate information you have, the more clean claims you can compile.

Medical Transcription

The recording of the meeting will be sent to a qualified medical billing company, who will enter all this information in a medical script. It can be used later as a reference or updated with new information if the patient comes back for another check-up.

This step needs to be meticulous as it is used to assign the correct treatment and for follow-ups. Any error can result in a poor decision. 

Also, this script or claim is what the medical bill will be based on, and any mistake can lead to the rejection of the claim.

Medical Coding

The American Medical Association (AMA) has provided the guidelines that professional coders or medical billing outsourcing companies should follow for medical coding. It is a manuscript of knowing that how they can convert all of the patient’s information into alphanumeric codes.

It can include:

• Patient's reason for a visit
• Diagnosis
• Treatment is given by the healthcare provider
• Location of medical service, etc.

Coders use the Healthcare Common Procedure Coding System (HCPCS) and Current Procedure Terminology (CPT) to assign codes. It helps the insurance providers assess the amount to be paid.

Charge Entry

It is the first step in the preparation of the claim for the insurance company and consists of the expenses of the service provided by the clinician. All this information is added to the overall sum of the treatment by the medical coder. The form must be free of any mistake, as it can lead to either reduced payment or a claim rejection. For this reason, clearinghouses are sent the claim forms before the insurance companies nowadays.

So that if there are any issues related to the information in them, they can be sent back or rejected. This way, corrections are possible before the final draft.

It consists of things like:

• Patient Information
• Medical History
• Procedures with their corresponding correct codes
• National Provider Index Number (NPI)
• Name of Insurance Provider
• Code of the place of service

Another aspect that guarantees success for the medical billing and coding process is the HIPAA-compliance. A medical practice cannot expect high reimbursements even if they are getting high collections but is not complying with the privacy policies. It will end up being penalized.

Read more at: https://www.p3care.com/blog/hipaa-medical-billing-is-more-important-than-you-think/

Claims Submission

Once everything, like the patient’s details, healthcare provider’s details, and the information about the service(s) provided, is added to the claim form, it is submitted to the insurance company.

These days, most medical billing companies send claims through a system known as Electronic Data Transfer (EDI). Plus, to ensure proper claim submission, there are three stages.

• Electronic Health Records (EHR) software checks to make sure the relevant fields are filled, along with the correct codes
• Verification of the patient's information by third-party EDI vendors
• Verification by the insurance company for all the information provided, and in case of any variations or inconsistency, claim returned or rejected

Denial Management

Insurance companies only accept claim submissions within a certain amount of time. Once they do and review them, there’s one of two possible routes they can take:

• Either they pay the entire sum
• Or they pay a part of it and deny the rest of the charges

If it is the second route, the medical practice has a team that reviews the claim and resends it to recover denied charges. A list of trends in this regard is also noted so that future rejections can be avoided.

Accounts Receivable (AR)

Even after corrections are complete, there can be a chance of the claim still being denied. In this case, the medical billing company works rigorously with the insurance company to gather more information about the payment denial. The medical coding, insurance coding, and charge posting sheets are shared as well to check if there were any errors.

Collection of Payment

Once everything is cleared up, the insurance company can pay the claim in its entirety. The money is sent through a check or an Electronic Fund Transfer (EFT). If there are bulk payments, they will come with a summary called Explanation of Benefits (EOB). medical billing companies

The professionals at a medical practice or medical billing company are responsible for entering the information about the received payments into the EHR software.

And this completes the entire process of reimbursement.

Conclusion

Professional medical billing and coding companies are preferred by most medical practices. It is because they have the latest technology to take care of the entire process.

They can efficiently take care of the billing process and make sure that everything runs smoothly. Also, the margin of errors lessens considerably, as these people are trained professionals who remain updated with the issued guidelines. It ensures that

• The revenue stream remains uninterrupted
• And that the patients keep coming in for check-ups without worrying about payments

Plus, the medical practice doesn't have to spend time looking for a candidate who can take care of these billing and coding tasks.