Medical Billing: It's About Medical Insurance Claims PaymentIn the USA Medical Billing works like this: With new patients, the process starts when the patient walks up and signs in at the front desk. Whoever is manning that front desk will than ask to see your insurance card, which will verify that the medical provider gets paid for his/her services. A copy of the card will be made and then it will be returned to you. Next are forms to fill out, which will usually again request that you provide information on your medical insurance carrier. Until these steps are completed to the satisfaction of the front desk gatekeeper, a new patient will not see a physician, therapist, nurse, or any other medical personal. Effectively, what this means is that the medical billing process has already started. Now let's take a look at the actual process flow of Medical Billing: · After treatment of the patient, the doctor updates the medical record of the patient that contains a summary of the treatment, diagnosis, and the patient's demographic information. The patient record will also have details on the nature of illness, medication details and the patient's personal information of the patient. · All the details from the case diagnosis by the doctor provides input to the level of service which is important to bill the insurance company. All forms of diagnosis are further categorized into two medical billing codes - ICD9 and CPT. These codes are then further generated to an electronic or paper version of CMS1500. · The CMS1500 is submitted to an information warehouse in case of electronic data interchange. In case of paper submittals, this billing record is submitted to the insurance company. · Once the insurance company receives the claim, it starts processing it. This process starts with verification of the claimant's insurance information - patient's claim eligibility, healthcare service provider credentials, and the reason for the treatment. · If all that information passes the insurers claim tests, the insurance company then pays the claim amount to the claimant. In case, the claim fails to clear the tests, the claimant will be informed of the rejection. · If and on receiving the rejection of the claim information, the healthcare service provider must decode the information, do some reconciliation with regards to the original claim and resubmit. The complexity of this process comes to the fore here with the provider submitting repeat claims until such time that the insurer accepts the claim and pays it in full. The Medical Billing process is exhaustive demanding absolute correctness of the information that is submitted to the insurance company. This requires exactness in coding including knowledge of the various plans of the insurance companies, and what payment/reimbursement amounts are offered by the different plans for specific treatments. For the treating healthcare provider that puts the onus on them to know how much they are allowed to claim for an office visit, a diagnostic procedure, or any other type of treatment |