Wednesday, April 3, 2024

10 steps in medical billing process

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What are the ten steps in the medical billing process?

The medical billing process is a set of operations carried out by billing specialists to guarantee that medical practitioners get compensated for their services. In other words, medical billing is a procedure used by health care organizations and insurance firms to handle medical treatment and service expenses. Based on the conditions, it may take only a few days to finish, or it may take several weeks or months. While each medical office’s procedure may vary somewhat, below is a broad overview of a medical billing system.

Medical billing services are divided into three stages: check-in, claim, and post-claim. However, this procedure is growing more complex as players become more cautious and meticulous in verifying the integrity and avoiding fraudulent actions. As a result, before beginning the medical billing process, it is critical to understand each stage in detail properly.


Every business has its method or process that helps it to be profitable. Similarly, medical billing firms adhere to a distinct procedure to remain ethical and commercial in the marketplace. Therefore, medical billing services include Revenue Cycle Management as an essential component. Revenue Cycle Management provides a system that disputes every denials and posts payment on schedule.

So today, we will discuss ten steps in the medical billing process that you must have better understand before choosing medical billing.

Implementing a proper medical billing process may expedite the procedure, decrease complexity, and result in speedier claim submission and reimbursement. Here are ten measures to make the medical billing procedure more accessible and less time-consuming for your organization.

Steps in the medical billing process :

  1.     Patient registration
  2.     Insurance verification
  3.     Encounter
  4.     Medical transcription
  5.     Medical coding
  6.     Charge entry
  7.     Charge transmission
  8.     AR calling
  9.     Denial management
  10.     Payment posting

Let us discuss them in detail.

1. Patient registration

Patient registration is the first step in the medical billing and coding process. Before the treatment, the front desk personnel collects the essential data and information from the patient to schedule an appointment with the doctor. Then, medical billing firms use the patient’s medical information to establish the claim as quickly as the patient registered with the practitioner.

Furthermore, experienced medical billers check that the information supplied in the initial stage is correct. Check-in and check-out are essential components of the patient registration procedure. To be more specific, the front desk personnel passes out a form to the patient to gather information.

Even though the medical billing staff has the information, they validate it with the patient’s identification or driver’s license to ensure their identity. Then, when the patient checks out (following the visit), the information and services given are collected into a superbill. From here, the entire medical billing and coding procedure begins.

Patient registration step:

  • Data and information, including insurance validation, are detailed to file a claim for healthcare services given.
  •   To enable faultless invoicing, the RCM organization maintains a firm grasp on the patient’s data.
  • The procedure described above is solely applicable to the new appointment. The information from previous meetings will already be preserved.
  •   It allows medical billers to double-check the information given before submitting a claim.

2. Insurance verification

In this phase, the patient’s insurance is entirely verified by outsourcing medical billing services. The healthcare plan is extensively examined to ensure that eligibility and policy compliance are met. Following the verification process, billing specialists discuss the patient’s responsibilities, including deductibles, copayments, and out-of-pocket expenditures.

Pre-authorization from insurance providers is required in some situations before services are given. It happens in this phase as well. To preserve and validate information, many medical billing systems employ digital methods.

The biller verifies insurance coverage to eliminate any questions about what the insurance provider will cover. If such insurance does not cover the services, the biller informs the patients that they will be responsible for the whole amount.

3. Encounter

Terminology for a meeting between a patient and a provider in which the patient describes the problem and the provider analyzes the patient’s condition to make a decision that will aid in the patient’s recovery. It is a session that has been captured using audio or video technologies. Claims may be perfectly prepared if the information is correctly gathered and the session is carefully recorded.

When a patient meets with a healthcare professional, the specifics of the ailment and the treatment provided are recorded, whether audio or video. These details may be documented in front of the patient or after the meeting. It clarifies the illness as well as the medications given by the healthcare practitioner. Then, they send the record to the RCM firm. 

4. Medical transcription

A medical script is created by transferring recorded audio or video. The hand includes the whole state of the health record. Medical transcription is the process of transcribing voice-recorded or video-recorded medical reports by healthcare practitioners. It is critical to keep a prepared and modified file on hand. Ascertain that the transcription contains no misleading or incorrect data, which might affect the patient’s health.

Specialists listen to the recorded session and enter information into a medical script, then used to finalize and manage the patient’s health records. This must be an error-free procedure since updated records are utilized in future follow-ups, providers look to these documents to offer treatment, and any inaccurate information curtails a patient’s medical history, resulting in improper decision making. Perhaps not that, but the paper is also utilized for invoicing reasons. Thus any incorrect information would impact the claim as well.

5. Medical coding

According to the American Medical Association’s guidelines, a group of professionals reads the document created from the recording and converts necessary details such as where the service was provided, the reason for the visit, the measures taken by the provider to solve the current condition, and so on into the numeric or alphanumeric-codes. It is necessary for two reasons: initially, it is simple to comprehend, and later, it is a legal necessity.

Also, in simple terms, medical coding is,

• Medical coding is the process of converting a patient’s condition, medical treatments, and medical prescriptions into medical codes.
• For a time-saving and straightforward operation, the transcript information is transformed into medical codes.
• Reading the patient’s entire medical history takes more time. As a result, it is programmed into codes.
• Medical coding is only done by the medical staff. Therefore, they should be knowledgeable and competent in certain areas of medical coding.
• Coders depend on patient condition and service given to the patient to convert the medical record into a medical code.

6. Charge entry

Charge entry is the next step in the medical billing process. The expense expended to deliver the service or the most significant collectible amount is included in the costs coded by the coding crew; it is one of the stages necessary to produce the claim form that needs to be submitted to the insurance company; without the stated value, no money can be collected. Again, specialists monitor and control to ensure that the correct discount is applied, as an error may lower the claim payout.

7. Charge transmission

After successfully setting up the claim by entering patient information, provider information, services given, and so on, the claim has become ready for submission for payment. Medical billing claims are transmitted in a safe and encrypted manner.

Transmission errors are classified into three types:
• Scrubbing- Required fields must be filled out correctly. Otherwise, the program would reject the claim.

• EDI rejection- Incorrect entries in the patient’s record will result in claim rejection via EDI.

• Payer rejections- Claims are rejected based on insurance restrictions and payer data.

Only once these three stages are completed denials or payments executed.

8. AR calling

These experts manage insurance claims that have been refused and are not being paid, even after remedial actions have been made to make a claim payment. They focus on thorough follow-up with health insurers, gathering facts about the rejection, researching, and organizing to keep revenues flowing.

They communicate accurate information with teams such as Insurance Verification, Coding, and Charge Posting for future claims. They are also in charge of managing and preserving inbound and outbound insurance communications.

9. Denial management

Insurance companies will only process claims that are received within the time frame stated. When a claim is accepted, it goes through a procedure called adjudication. After applying specific checks to the lawsuit, they determine whether to pay or deny it; occasionally, they spend part of the claim while rejecting the remainder of the costs.

Professionals that handle denials prioritize the claim based on the time remaining for submission to insurance and the amount remaining to be recovered, guaranteeing optimum revenue production. In addition, they track denials to identify patterns of denial and implement remedial actions to ensure that future claims are not refused.

10. Payment posting

Payment posting is the final step in the medical billing process, which allows the team to stay up to speed on the payment status. Patients are given EOBs (Explanation of Benefits) and ERAs (Electronic Remittance Advice). The Payment Posting team additionally verifies that the payment received is correct.

The posting team captures denials and payments using EOB or communication receivable from insurance carriers. The posting team must match the significant payment liabilities with the cheque amount. The patient and insurance revenue will be computed using the payment deposited to the practice accounts.

These ten steps take the medical billing process towards the next level of Revenue Cycle Management by ensuring consistent revenue increase and access to a massive number of medical claims with no mistakes and fewer rejections.

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I am a medical biller, a blogger and have 20 years of experience in medical billing, medical billing management, and medical assistant. My background includes positions as a clinical medical assistant, medical records technician, medical office manager, biller, and coder. I am certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) and by the Practice Management Institute (PMI) as a Certified Medical Office Manager (CMOM). As an office manager/biller/coder, I was a member of the Michigan Medical Group Managers, Michigan Medical Billers Association. I also served as a committee member of the Michigan Osteopathic Association of Practice Managers Education Committee.

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