Medical billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government-owned.
The medical billing process is an interaction between a healthcare provider and the insurance company (payer).
The interaction begins with the office visit: A doctor will create or update the patient's medical record(depends with the is an estalished or a new patient). This record contains a summary of treatment and demographic information related to the patient.
The information in the Medical rec The level of serords is coded into numbers, by professional or experienced coders.
usually these, codes are 5 digit numbers or the alpha numeric.
the codes are assigned from ICD ------->international classification on diseases
CPT-------> current Procedural Terminalogy
HCPCS-->Healthcare common procedural coding system
Once the procedure and diagnosis codes are determined, the medical biller will transmit the claim to the insurance company (payer). This is usually done electronically by formatting the claim as an ANSI 837 file and using Electronic Data Interchange(EDI) to submit the claim file to the payer directly or via a clearinghouse.
Historically, claims were submitted using a paper form; in the case of professional (non-hospital) services and for most payers the CMS-1500 form or HICFA-1500. The CMS-1500 form is so named for its originator, the Centers for Medicare and Medicaid Services. To this day about 30% of medical claims get sent to payers using paper forms which are either manually entered or entered using automated recognition or OCR software.
The insurance company (payer) processes the claims. The insurance company has medical directors review the claims and evaluate their validity for payment using the patient eligibility, provider credentials, and medical necessity.
Approved claims are reimbursed for a certain percentage of the billed services. Failed claims are rejected and notice is sent to provider. Most commonly, rejected claims are returned to providers in the form of Explanation of Benefits (EOB's) or Remittance Advice or Correspondance's.
Upon receiving the rejection message the provider must interpret the message, reconcile it with the original claim, make required corrections and resubmit the claim.
This exchange of claims and rejections may be repeated multiple times until a claim is paid in full, or the provider relents and accepts an incomplete reimbursement.
The frequency of rejections, denials, and over payments is high , mainly because of high complexity of claims and/or errors due to similarities in diagnosis' and their corresponding codes. This number may also be high due to insurance companies denying certain services that they do not cover in which case small adjustments are made and the claim is re-sent.
A practice that has interactions with the patient must now under HIPAA send most billing claims for services via electronic means
In order to be clear on the payment of a medical billing claim, the health care provider or medical biller must have complete knowledge of different insurance plans that insurance companies are offering, and the laws and regulations that preside over them. Large insurance companies can have up to 15 different plans contracted with one provider. When providers agree to accept an insurance company’s plan, the contractual agreement includes many details including fee schedules which dictate what the insurance company will pay the provider for covered procedures and other rules such as timely filing guidelines.
Providers typically charge more for services, than what has been negotiated by the doctor/hospital and the insurance company, so the expected payment from the insurance company for services is reduced.
The amount that is paid by the insurance is known as an allowable amount.
For example, although a physician may charge $100.00 for a medication management session, the insurance may only allow $70.00, so a $30 reduction would be assessed. This is called a "provider write off" or "contractual adjustment." After payment has been made a provider will typically receive an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) along with the payment from the insurance company that outlines these transactions.
Why Won't the Doctor Do the Billing?
Traditionally doctors graduate from medical school with the expectation that they will practice medicine and deliver patient care. Running a business, however, is not part of the their premise. To them, running a business is for business professionals. However, the catch twenty-two is that medical practices ARE a business and need to be properly managed and run as such. Running a medical office includes certain administrative procedures, and getting paid for services is part of any business. 
This means:
Collection of accounts receivables
co-payments
claim denial appeals
and reminders for past due accounts
However, it is not the doctor's job to do the billing! Physicians don't have to do everything themselves. Running a medical office business requires a full team of medical office staff with each one playing a vital role to keep the operation going.
The Art of Medical Billing
Medical billers not only review charge slips and track payments, they also analyze records to produce customized reports that show profitability or areas in need of improvement. Such reports are critical when decisions need to be made on renewing and negotiating contracts.
They also advise physicians of fee structure changes, new coding practices, and ways to improve the office's bottom line. Most medical billers also handle the offices dictation transcription. This saves the medical office money and allows the healthcare providers to comply with the strict HCFA rules, which mandate clarity of all Medicare claims.
A Highly Skilled and Knowledgeable Expert
Medical billers use the HCFA-1500 form to submit health insurance claims to insurance carriers. They must know appropriate responses to a variety of billing and legal situations.
Bill collection, release of patient information/records, patient confidentiality rights, subpoenas, workers’ compensation rules, and Medicare regulations for reimbursement are complicated areas and must be handled competently and with care.
To get paid an Assignment of Benefits (AOB) is used, which is an authorization directing the insurer to make payment directly to the provider of benefits, rather than to the insured. The insurance carrier however, is the one who determines whether benefits are payable.
Naturally, as the expectations and standards for proper coding and billing procedures become more stringent, medical billing and coding companies are rapidly becoming a vital segment of the national health care industry. So much so, that traditional medical staffing firms have taken note, as they have expanded their suite of services to include physician coding and billing. Furthermore, publicly traded companies are quickly consolidating the medical billing and coding segment through the acquisition of smaller players.
My contact info:
Veeresh Bikkaneti, CMRS(Certified Medical Reimbursement Specialist)
Email:galaxyblackhole1@gmail.com
medicalcodingandbilling@myspace.com
blogs: http://medicalbillingandcoding.blog.com/
http://medicalcodingandbilling.over-blog.com/
mobile: +91- 984.946.1587
