Wednesday, June 13, 2012

The Medical Billing Claim Process

When a patient visits a physician, the doctor writes down the observed conditions and treatment. This information is then given to a medical coder who assigns the appropriate ICD-9 diagnosis and CPT medical billing codes (and CPT modifiers if necessary). The coder may get a written or voice audio dictation file from the doctor that contains the details of the diagnosis and procedures performed on each patient.

The coder may use reference books to look up the correct diagnosis codes (like the ICD-9-CM Expert for Physicians - 2010 Edition) and the corresponding CPT treatment codes and modifiers (CPC-Current Procedural Coding Expert - 2010 Edition). There are also online coding references such as CodingToday that have the latest treatment and diagnosis codes. These services require a subscription for access but can be a real time saver.

It’s very important that the ICD-9 and CPT codes be correct so the claim doesn’t get rejected. Depending on how thorough a doctor is, coding from the providers dictation or handwriting can be very time consuming. However once you get to know the doctor’s preferences and habits the process goes much more efficiently.

This is where the medical billing specialist gets involved. The codes are then typically entered or checked on a superbill or patient encounter form. You've probable seen one of these when visiting the doctor. Some practices now do this electronically. They take the superbill and input the information into the electronic medical billing software. Paper claims are printed out on a CMS-1500 insurance form and mailed to the insurance carrier.

Electronic claims are sent as an electronic file either directly to the insurance company or to a clearinghouse. The clearinghouse takes the claim information, checks the claim for errors, and sends the claim information electronically to insurance companies. Most clearinghouses have a large payer list and can send claims to mostly all of the major insurance companies. This can be a real time saver as each insurer can have different submittal requirements and interfaces. Claims sent electronically are paid much faster than paper claims. Depending on the practice this could be just a few claims or over 40 claims a day.

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. Some patients also have secondary insurance which requires a second claim be submitted with the EOB to the secondary insurer.

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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