The Medical Billing Process, to put it simply, is a process of making sure a doctor and health institution get paid for their services. This could only take days to push through, however, in some cases, it can take several weeks or even months. A good medical billing expert knows how to properly get the providers paid but the task is not easy as it is not fully automated (as to what others might think) and requires a deep understanding of the system. Their task involves analysis of the doctors’ chart records and notes, rectifying patient and insurance details, assigning correct codes per disease, etc.
A lot of work and necessary information needs to be checked, validated, and included for an expert to come up with just a claim. A Medical Billing Expert might as well be called an Insurance Expert since his job mostly revolves around insurance and the health insurance system is very complex and always changing.
What Happens in Medical Billing?
1. Creating a Patient Profile
This pertains to the basic information of the patient. It also asks the reason for the visit of the patient and most importantly the covering insurance and insurance policy number of the patient.
2. Verifying Insurance Coverage
This simply means that the medical biller will inspect the coverage of your insurance. Certain medical procedures cannot be avoided sometimes during clinic visits, therefore to avoid surprise out-of-pocket payments, the patient can be notified early on if he would have to pay for the said procedure.
3. The Superbill aka Encounter form
After No. 1 and 2 above have run smoothly, and patient consultation has commenced, the patient will then be given a diagnosis after the consultation which will then a medical coder will translate to its corresponding code. This is almost like a summary of whatever happened that day from the moment the patient walked into the clinic up to his leave. This will reflect what services have been offered to the patient and will determine which of those services is/are subjected to insurance coverage and which of those are not.
4. Claims
The superbill is carefully created by the medical biller to generate a strong insurance claim. The claim should again be reviewed carefully and standards for HIPAA should be met along with proper coding format. After the claim has been double–checked, this will be submitted to the insurance company but most of the time, third-party companies act as a bridge between the two parties. The paying party will now determine if the claim is accepted, denied, or rejected.
After the claim has been submitted to the paying party, it will now be scrutinized for compliance and completeness. Depending on the payer’s approval, the total amount will also be determined. Even if the medical biller has done his part in creating an efficient claim, the paying party will still determine if the claim is approved/accepted, rejected, or denied.
A Rejection can happen before the adjudication process itself. It can happen somewhere in between the flow of claim transmittal to the clearinghouse going to the paying party. To make it simple,
Rejection can be made by the clearinghouse itself after he checked some minor discrepancies in the claim and on the other hand, once it has been cleared from the clearinghouse and reached the payer itself, it will then be again scrutinized by that party before allowing the claim to come through.
A Denial is when the payer has allowed the claim to come through and will now review the claim against the patient’s coverage together with their internal policies but found out there are, for example, some things that did not match up or some service has been made that went against their medical policies and then the payer says “No”.
Medical Billing and Medical Coding
The two are in no way the same but work systematically with each other. Both require a decent medical background in the terminologies, pathophysiology diseases, and basic anatomy and physiology to grasp fully the medical language in the workplace. Medical coding utilizes ICD 10, HCPC, and the CPT to tell the payers what procedures were done and why were they done. Medical billing, on the other hand, begins prior to the medical coding and serves as an intersection point between the physician, the insurance, and the patient. The flow chart of an entire patient consultation is governed by the medical billers and they make sure the continuity and effectiveness of the revenue cycle management.
The cost of healthcare is not always 100% free. The medical billers will charge the patient-client the remaining uncovered expenses and do follow-through on delinquent bills. Transparency and honesty in creating claims are the keys to maintaining a healthy relationship between insurance companies and health institutions. Certain fraud issues are to be avoided if the billing and coding are done correctly. Upcoding and downcoding are the two common frauds of medical billing. “Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursements” (Coustasse A, Layton W, Nelson L, Walker V. UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING? Perspect Health Inf Manag. 2021 Oct 1;18(4):1f. PMID: 34975355; PMCID: PMC8649706) while downcoding is the opposite.
Downcoding a lesser code on a claim, perhaps is done to induce patients to keep coming back for other services. Both upcoding and downcoding are significant because these actions have been interpreted as a basis for abusing and defrauding the federal government and its programs. According to CMS, “abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program.” (https://healthlawcenterplc.com/are-you-defrauding-medicare-by-either-upcoding-or-downcoding-submitted-claims/)
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