Medical billing process flow

The Medical Billing Process

When a patient visits a physician, the doctor evaluates the patient and writes down the observed conditions and treatment. This information is then given to a medical coder who takes this information and assigns the appropriate ICD-9 diagnosis and CPT treatment codes (and code modifiers if necessary).

These codes are then entered on a superbill or patient encounter form. You've probable seen one of these when visiting the doctor. Many physicians don't even use a coder and do this there self by checking or circling the diagnosis and treatment codes directly on the superbill. The majority of patient visits involve using a lot of the same codes.

This is when the medical billing specialist gets involved. They take the superbill and input the information into the practice management (or medical billing) software. Paper claims are printed out on a CMS-1500 insurance form and mailed to the insurance carrier. Electronic claims are sent electronically either directly to the insurance company or a clearinghouse.

If the claim is rejected, the medical billing specialist follows up to find out why it was rejected, correct the claim, and resubmit. An appeal may also need to be written and submitted with supporting information to the insurance company.

When a payment is received from the insurance carrier, it is accompanied by and EOB (Explanation of Benefits). This information is then entered into the medical billing software. If there is any patient responsibility such as co-pays and co-insurance, a patient statement is printed and mailed. This is usually done in batches on a monthly basis.

Sometimes a patient has questions about their bill. This requires the medical billing specialist to look up their account information and explain the charges and why they were not covered. Many patients don't understand the limits of their insurance coverage and must be referred to their insurer to explain.

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