Health Insurance

Understanding Your Health Insurance and Medical Billing

Medical Billing
Avatar
Written by Brandon

What is medical billing?

Medical billings is a form or kind of healthcare payment service, which involves a healthcare service provider submitting, following up on, and appealing claims with health insurance companies to get paid for services rendered. Services, in this case, could include testing, treatments, and procedures.

This process of medical billing was adopted by insurance companies and healthcare institutions to settle medical treatments, procedures, and services bills. There are processes to Medical Billings but first, I would like to explain some terms which might pop up regularly in the course of this article.

MEDICAL CLAIMS

What are Medical claims?

Medical claims are medical bills that are submitted to the health insurance companies and other insurance providers for treatment or services rendered to insured patients by healthcare providers. In other words, when you visit a hospital or any health care center, your treatment or whatever services rendered to you generates a bill, which when submitted to your insurance company becomes a claim.

There are two most common forms of the claim and they are CMS-1500 and the UB-04. These two forms of claim are often misplaced and that is not supposed to be so. Although they operate similarly, they cannot be used interchangeably. 

MEDICAL BILLERS

A medical biller is a professional, who translates healthcare services into medical claims which are in turn submitted to the Insurance Companies. The duty of the medical biller to follow up on claims to make sure that providers get paid. Some medical billers might handle both coding and Billing while others specialize in just one. It depends mostly on the job description.

BILLED AMOUNTS

Thus is a medical billing terminology that deals with the specification of the amount billed by the health care service provider for the service he or she provided to the beneficiary and is entered at the time of charge entry by the billing office.

ASSIGNMENT OF BENEFIT (AOB)

 Assignment Of benefit (AOB) is simply a document authorizing insurance payment directly to the hospital or any health care provider, for a patient’s treatment. This document must be signed by the patient.

BENEFICIARY

This is a Health Insurance Terminology used to refer to a person or several persons covered by a particular health insurance plan.

MEDICAL CODING

Medical Coding simply refers to providing the right information concerning the patients’ disease or state of health through diagnosis codes. These codes are then forwarded to Insurance Companies, Medicare or other payers for reimbursement. It is a key factor in acquiring insurance reimbursement and it is used in three maintenance of patient records. Coding claims accurately inform the insurance payer about the injury or illness of the beneficiary and again method of treatment. Medical Coding can involve various types of codes including ICD codes, CTP codes, HCPCS codes, modifiers, and DRG codes. These coding set are pertinent to communication and for billing purposes

Now that we are clear on the terminologies involved when discussing medical billings, I would move on to list and explain the processes of medical billing.

PROCESS OF MEDICAL BILLING 

The medical billing process starts when a health care provider treats a patient and sends a bill of services provided to the beneficiary to a designated payer which is most at times a Health insurance Company. The insurance information of the patient is added. Also, the demographic data of the patient is included. Generally, there are three main stages of the medical billing process.

  • Check-in
  • Claim
  • Post claim

This process, however, seems to become more complicated as time passes to ensure authenticity and avoid fraudulent activities. Here’s a list of the process medical billings undergo.

  • Patient registration
  • Insurance verification
  • Coding
  • Cross-checking codes
  • Filing the charges
  • Auditing Claims
  • Claim Submission
  • Follow up
  • Reimbursement
  • Denial management

PATIENT REGISTRATION

Patient Registration involves documentation of all the information regarding the beneficiary which comprises contact information, insurance policy number, medical history, medical reports, and current insurance card.

 INSURANCE VERIFICATION

Insurance verification involves double-checking insurance information provided by the patient. Verification of eligibility status, coverage, benefits, and conditions of the insurance.

 CODING

The Coding Stage involves entering the right information concerning the symptoms, diseases, and medical procedures. This is don’t with the use of diagnosis codes. Billed amounts are also added here. Codes are used for standard communication of supplies used in the treatment of human health conditions.

CROSS CHECKING CODES

The Process of cross-checking codes involves making sure each code is entered correctly in the document. Cross-checking for errors in translation is also carried out in this stage.

 FILLING THE CHARGES

This stage involves documenting all the charges for the medical procedure which the patient would undergo. Charges and details with regards to procedures, diagnosis, and treatments are documented in this stage. If there’s a case of an accident, it will also be mentioned.

 AUDITING CLAIMS

To ensure avoidance of omissions and errors, the document undergoes thorough scrutiny and examination in this stage.

CLAIM SUBMISSION

Many insurance companies follow common guidelines for submission of the claim but a few others have their specified procedure. Under normal circumstances, once an accurate medical document is created, it is sent to the payer. That simply means the health insurance provider for payment.

 FOLLOW UP

This stage involves receiving a timely update on the claim that has been submitted. It also involves monitoring the claims and keeping up with the insurance company via phone calls and emails.

 REIMBURSEMENT

In this stage, once payment is made by the insurance company, the amount received is placed under review. The patient’s account will be updated as soon as confirmation on the right amount takes place. If there is a balance to pay, the patient will also be notified.

 DENIAL MANAGEMENT

This is the final stage of the process of medical billing. At this stage, what is mostly carried out is rechecking of insurance documents, coordination with insurance companies in case of rejected or unpaid claims which can occur due to error or insufficient funds. 

Leave a Comment

error: Content is protected !!