Medical Billing Procedures
Medical billing procedures are the guideline physicians and other health care providers must follow in order to receive payment for the services provided to their clients. The process requires knowledge in a variety of areas and practical know-how of the medical billing process to navigate through the mass of health care regulations and insurance company requirements.
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Function
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Years ago, medical billing was handled almost exclusively by the physician and maybe an assistant. Now there are medical staff and outside vendors who specialize in medical billing. There are a range of tasks associated with the billing process, including addressing client's questions about health care plans, or solving discrepancies with insurance providers and state agencies. The primary job of the medical biller involves coordination and organizing the bills and statements for health services rendered, checking them for accuracy and submitting them for payment.
Claims
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When clients complete their visit with their health care providers, the medical billing professionals starts a process called a claim. Somewhere along the patient-physician relationship, the patients sign the claim, which includes an "assignment of benefits" provision, which tells the insurance company to pay the benefits to your doctor or dentist. If there is an outstanding balance remaining on the account, the patient is billed directly. There are numerous fields that must be filled out on the form. Information is required on different parties involved, including the insured, the insurance holder, the insurance provider and the health care service provider. Information may also be required about the patient's medical history and the health issue that led to the claim.
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Medical Coding
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In order to properly prepare a claim, it takes a medical coder with excellent knowledge of Current Coding Protocol (CCP). The CCP is categorized into various sections, including evaluation & management, anesthesia, surgery, radiology, pathology and laboratory. It contains the medical procedures and the proper codes. It is essential that the coding be accurate in order for the provider to be properly reimbursed.
Insurance Claims
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Medical billing procedures call for the claim to be submitted on Form CSM-1500. This is the standard form that health care providers must complete in order to receive reimbursement from most insurance companies, Medicare and Medicaid. It used to be called the HCFA 1500. Medical billing procedures also involve the completion of institutional claim form UB-04, which is used by clinics, health agencies and ambulance companies.
Payments
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The claims are submitted to third-parties that are responsible for paying the bill, including government insurance programs, managed care organizations and private insurance companies. Generally, a patient may be responsible for paying a deductible or co-payment upfront. The insurance carrier is responsible for paying the balance. Health care provider receives the payment along with a document known as an explanation of benefits (EOB). The EOB outlines what was paid to the payee as well as what is not covered.
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