Lisa Collins
Instructor: Mrs. Donna Purvis, MBA
HLTH245 Principles of Reimbursement Management
September 29, 2015

Ten Step Billing Process

The ten steps of the medical billing process have been divided into three categories: The visit, the claim and the post claim. Following the billing steps to complete correct claims ensures that providers are paid accurately and timely for services and procedures.
The Billing process begins with the preregistration of patients. Collecting personal, basic demographic information, and insurance information and entering that information into the database. All of this personal information can be referred to at any time during the medical billing process. Keeping up to date patient and insurance information makes patient check in more efficient and eliminated potential billing errors. Confirming financial responsibility is the next step in the billing process. Once a patient’s information has been updated in the computer system it is then the medical staffs’ responsibility to determine who will be paying for the services rendered for the appointment. Insurance providers are contacted and benefits are verified as different plans have different levels of coverage. Once the medical staff is aware of what the allowable insurance benefits are, contact with the patient should be made so the patient is aware of their responsibility for out of pocket, non-covered expenses, co-payments, and deductibles. During the appointment, the physician makes notes of the examination and services provided. These notes become part of the patients’ medical records and are key to creating an accurate medical bill to insurance providers and to patients. Medical coders translate all services, procedures and diagnosis into a series of medical codes. Before a claim can be sent off for reimbursement, the medical biller must confirm that each charge is related to a specific procedure code. The billing process must be compliant with requirements set by the Health Insurance Portability and Accountability Act (HIPAA), and the Office of Inspector General (OIG). Achieving necessary compliance in medical billing ensures that fees are charged accurately. The medical biller confirms that each charge coordinates with the appropriate procedure code. The medical biller must also determine if the code is billable under the insurance providers’ or payers’ rules. Bills sent out to insurance payers that contain services that are billable outside of the payers rules result in denied claims. Denied claims are a time consuming, resource wasting complication for all parties.

Once all diagnosis and service codes have been coded and checked for compliance the bill is made ready to send to the insurance payer and to the patient. The claim contains all the necessary diagnosis and procedure codes pertaining to the patients’ medical appointment. An internal audit of the claim before transmission is the best way to ensure timely reimbursement for services and procedures. Most medical practices transmit claims through electronic software. The electronic transmission of claims expedites the processing of the claims. When the insurance payer receives the transmitted claim, that claim is reviewed in a process called adjudication. Adjudication is the process followed by the health plans to examine claims and determine benefits. ( Valerius, page GL-1) It is during the adjudication process that the insurance payer determines whether they will pay the entire bill, a portion of the bill or deny the claim. The decision made by the insurance payer is based upon the policy that the insurance payers’ hold with the patient and the contract with the medical service provider. Once the payer has made a decision on the claim a report is sent back to the biller. At this point the medical biller reviews the repot and compares the payments to the billable services to ensure that all claims are being billed and paid appropriately. If a discrepancy is found, the biller can enter into the appeal process. This process is crucial to ensure that the medical provider receives the maximum appropriate reimbursement as agreed in the contract between the medical provider and the insurance payer. If the codes listed on the insurance payers report match the codes sent by the medical practice on the report, then all charges are compliant and these payments are then processed to patients’ accounts. All balances for co-pays, non-covered services, and deductibles are then billed directly to patients. It is very important that all the information obtained for this billing process be reflected on the patients bill. When a patient is sent a bill with the remaining balance for the medical services provided, a payment date is set and listed on the bill itself. Once the patient’s payment is received, and the healthcare provider has been reimbursed for all services provided, the information is filed in the patient’s record and the transaction is effectively closed. It is the final three steps in the billing process that address the remittance of the advice. An RA covers a group of claims, not just an individual’s claim, so the medial practice staff member must break the RA down review the individual claims for the appropriate payments to individual accounts. Medical billing staff then authorize the insurance payer to provide an electronic funds transfer of the payment. Payments are direct deposited into the medical practices bank account, and under the Affordable Care Act, require both an EFT (electronic fund transaction) number and an ERA (Electronic remittance Advice) number. Posting of this transactions applies the payments to the individual’s accounts. Reconciling the posting of the payments is a mathematical equation ensuring all the billable amounts minus the adjustments equal the total amount paid to the provider. The medical billing process has many areas where discrepancies can occur. These areas must be monitored carefully to ensure that all ethical dilemmas are avoided. Physicians make verbal notes or electronic notes. Then these notes are documented and interpreted for diagnosis and billing codes. A physician may make these notes unclear and the interpretation can be an avoidable error in the billing process by over billing for services not provided. Communication at all steps is critical to ensure that services are actually provided so that they can be billed appropriately. In my current position, I work in the billing office of a local hospital. I am a Medicaid Eligibility Specialist. It is important for the internal billing process within our department for communication to be open between the patients, the medical biller and myself. It is a necessary part of the billing process for my coding to be correct for the patients accounts. Keeping updated records of the patients’ employment and other insurance codes, keep the patients eligible for a certain income based Medicaid program. Not only does keeping updated records help my patients, it also ensure that claims are transmitted appropriately and reimbursed accurately. A Patient the has not reported a change to the other insurance, has that insurance coded as primary and Medicaid secondary. When the Medicaid biller transmits the claim to Medicaid, and that claim is rejected as not billable as primary insurance it is frustrating to all involved. It also creates a hardship for my patients that live on a fixed income and may not have the funds available to pay for services that were rendered but not covered or are not billable under Medicaid. It has become clear thru this learning of the billing process that keeping accurate records updated for the patient is crucial in receiving accurate and timely reimbursement for services rendered.

References:
Valerius, , Bayes, Newby, and Blochowiak. Medical Insurance An Integrated Claims Process Approach. Sixth ed. New York: McGraw Hill, 2014. N. pag. Print.
"You are just ten steps away from increasing the revenue of your practice." Medical Billing Process. isource, n.d. Web. 4 Oct. 2015. <ww.medicaltranscriptionsservice.com/medical-billing/billing-process-steps.html>.