The Ultimate Guide to Medical Billing

Front End Medical Billing

Front-end medical billing staff should know a lot about the types of payers that their company works with. Billers can make sure that patients are eligible for insurance by learning about the different payers and health plans that the organization accepts. They can also keep track of filing dates and which payers need services to be pre-approved.

Pre-registration and registration

When a patient calls the provider’s office to make an appointment or checks in at the hospital, the insurance claim processing starts. Staff usually get information about the patient’s background and insurance, or the patient fills out a registration form when they get to the place of service.

When the billing staff follows standard working procedures for registering patients, they are more likely to get the data they need without making mistakes. When figuring out a patient’s status and perks, as well as getting prior permission, having accurate patient info is very important.

Verification of insurance eligibility

The front desk staff has to make sure that the services are covered by the patient’s health plan before they can get paid. This step, which can be done over the phone or through an insurer’s online eligibility verification tool, checks the patient’s status, as well as their share, copay, deductible, and plan benefits for their field and place of service.

It’s also important to get the appropriate preauthorization. Most of the time, insurers need preauthorization before they will pay for medical services that aren’t done in a general care setting.

Point of service collections

After finding out about the patient’s benefits during qualifying verification, staff are told how much the patient owes. This lets the biller get the copay, deductible, coinsurance, or full amount due from the patient while they are at the front desk, either checking in or out.

Point-of-service collections are an important part of medical billing because they keep bad debts from being written off and keep the cost of following up with patients to make sure they pay their bills down.

Back End Medical Billing

Medical billers often consult with doctors to clarify diagnoses or gather patient data. The medical biller must read medical records and know CPT®, HCPCS Level II, and ICD-10 codes.

Charge entry

The encounter form tells charge entry workers what services and procedures were done and why. After service, charge entry workers input these costs and patient payments into the practice management system.

Charge entry personnel must ask the physician for extra information if an encounter form lacks a diagnosis, which payers need to justify medical services.

Charge entry also comprises charge capture checks to ensure all charges and receipts were included when reconciling patient charges. End-of-day reviews frequently include balancing encounter form charges and payments with a printed system report of the day’s charge entry.

Claim generation

Create the claim after entering charges and payments. Charges, revenue codes, CPT®, HCPCS Level II, and ICD-10 codes may be compiled.

Medical billers draft claims by physically or electronically retrieving superbill data. Remember that the superbill is the encounter form that lists the patient’s demographics, services, and diagnosis.

This itemized form provides the service date and the provider’s name, location, signature, and NPI. Provider remarks and comments may justify medically essential treatment. It may contain admission date and billing/referring provider information. A claim is generated from this data and delivered to third-party payers for payment.

Claim scrubbing

Billers verify procedure, diagnostic, and modifier codes during claim preparation. Complete patient, provider, and visit information is also part of claim scrubbing. Medical billers use claim scrubbing software to find and fix problems at this stage.

Instead of scrubbing claims, some medical practices and provider associations submit them to clearinghouses. Third-party clearinghouses evaluate, edit, and format medical claims before delivering them to insurance payers or returning them to billers for errors.

Claim forms

The Centers for Medicare & Medicaid Services designed the CMS-1500 and UB-04 claim forms, which medical billers use to be paid by insurance.

Providers and ASCs record professional services using the CMS-1500 claim form. Hospitals utilize the CMS-1450, often known as the UB-04 claim form, to record services and procedures.

Claims submission

HIPAA claim standards allow provider organizations to submit claims directly to payers utilizing electronic filing software. Most physician practices utilize a clearinghouse to submit claims.

Clearinghouses analyze claims for payer and federal compliance, among other services. The clearinghouse sends amended claims to the payer after returning claims to the biller.

Once the claim passes via the clearinghouse to the payer, the data file is analyzed and transformed to a claim form for the claims analyst or adjudicator. The clearinghouse report should reflect payer claim receipt. The payer may indicate a patient ineligible for service date.

Claim tracking

The medical biller’s task continues after the claim is filed. Billers must verify claims regularly. Clearinghouse dashboards allow billers easy access to claim progress information.

Once a claim reaches the payer, adjudication commences. The payer reviews and decides whether and how much to pay the provider during adjudication. It depends on the biller’s information and if the claim is genuine and should be paid.