MEDICAL BILLING

PROCESS
APPOINTMENT
 PATIENTCALLS /
WALKS TO THE
DOCTORS OFFICE
TO FIX THE
APPOINTMENT
 DATE OF SERVICE
 ONCE THE
APPOINTMENT IS
FIXED, PATIENT COMES
TO THE DOCTORS
OFFICE AND FILLS THE
DEMO FORMS (i.e., his
address with contact #,
DOB, Gender, SS#,
Employer Information,
policy name and number,
effective date etc.) and signs
the Breach of
Confidentiality.
 CHECK-UP
 DOCTOR CHECKS
THE PREVIOUS
MEDICAL HISTORY
OF THE PATIENT
AND CHEKS THE
PATIENT AND
DOES THE
PROCEDURE AS
PER THE CURRENT
ILLNESS.
MEDICAL TRANSCRIPTION
 DOCTORS GIVE THE
DICTATION TO THE
MEDICAL
TRANSCRIPTIONIST
FOR MEDICAL
RECORD KEEPING. (AS
IT IS MENDATORY IN
USA TO KEEP THE
MEDICAL RECORD OF
THE PATIENTS AT
LEASET FOR 5 YEARS).
 MEDICAL CODING
 AFTER THE MEDICAL
TRANSCRIPTION IS DONE, THE
DOCUMENTS / REPORTS ARE
SENT TO THE MEDICAL
CODING DIVISION TO GET
THE REPORTS CODED AS CPT
(CURRENT PROCEDURAL
TERMINOLOGY) AND ICD
(INTERNATIONAL
CLASSIFICATION OF DISEASE)
WITH THE HELP OF CODING
BOOKS AND MAINTAINING
CODING GUIDELINES.
MEDICAL BILLING
 ONCE THE CODING
IS OVER THE
CODED REPORTS /
SUPERBILLS COME
TO THE BILLING
DEPARTMENT,
WHERE BELOW
MENTIONED STEPS
ARE FOLLOWED:
 DEMO ENTRY

DEMOGRAPHICS OF THE NEW

PATIENTS ARE ENTERED INTO
THE BILLING SOFTWARE AND
UPDATION OF THE OLD
ACCOUNS ARE DONE.
CRITICAL FIELDS – DEMO
1.
ENTRY
PATIENTS INFORMATION:
NAME
2. DATE OF BIRTH
3. GENDER
4. SOCIAL SECURITY NUMBER (SS#)
5. ADDRESS (INCLUDING ZIP)
6. CONTACT NUMBER
7. RELATIONSHIP TO THE INSURED
8. MARITAL STATUS

INSURED’S INFORMATION:
1. ID Number
2. Name
3. Address )including Zip code)
4. Policy and Group Name
5. Insured’s Plan or Program name
6. Insured’s Date Of Birth
 CLAIM GENERATION OR
CHARGE ENTRY

ONCE THE ACCOUNT OF THE

PATIENT IS CREATED IN THE
BILLING SOFTWARE, CHARGE
CAN BE POSTED.
 CRITICAL FIELDS –
CHARGE ENTRY
a. Is the Patient’s Condition Related to: Employment, Auto Accident,
Other Accident
b. Name of Referring Physician
c. ID Number of Referring Physician
d. Diagnosis Codes
e. Prior Authorization Number (if applicable)
f. Dates of Service & Date of Hospitalization (in case of Inpatient)
g. Place and Type of Service
h. CPT
i. Modifiers (if applicable)
j. Linked Diagnosis Codes to the Procedure Codes
k. Days or Units (if applicable)
 CLAIM SUBMISSION
There are two ways to submit the claims to the insurance companies:

1. Electronic Media Claims submission (EMC): EMC is an electronic claims processing

system that enables a provider to submit his/her claims to the carrier more efficiently than
the paper claims, Provider can submit claim by modem, by magnetic computer tape or by
floppy diskette.
2. Paper Submission on different forms (such as CMS 1500, CMS 1450 or UB 92, ADA
992000)

Time taken by Medicare to pay a clean claim: Medicare statute provides for claims payment floors
and ceilings. A floor is the minimum amount of time a claim must be held before payment.
A ceiling is the maximum time allowed for processing a clean claim before Medicare owes
interest to the Provider of Services.

Physicians and suppliers who file Paper Claims will not be paid before the 26th day after the date of
recei0pt of their claims. Clean claims filed Electronically will be paid not sooner than 13
days after receipt.
 CLAIM ADJUDICATION

Processing of paper claims starts in the mailroom where the

envelops are opened, attachments unstapled, and clipped to
the claim. Claims are then scanned into the computer.

Processing of electronic claims begins when a file of

transmitted claims is received from the clearinghouse. (The
clearinghouse edits the claims before sending to the
insurance companies) and is opened in the claims
processing computer.
 STEPS (CLAIM
ADJUDICATION) -

1. The computer scans each claim for patient and policy identification
and compares them with the master policy file.
Claims will be automatically rejected if the patient and subscriber
names do not match exactly with the names on the master policy list.
Use of nicknames or typographical errors on claims will cause
rejection and return, or delay in reimbursement to the provider
because the claim cannot be matched with the names on the master
list.
2. Procedure codes on the claim form are matched with the policy’s
master benefit list. In the case of managed care claim, both the
procedures and the dates of service are checked to ensure that
services performed were authorized and performed within the
authorized dates of services.
 CLAIM ADJUDICATION –
Cont.
Any service determined to be a non-covered benefit is marked as an
uncovered procedure or non-covered procedure and rejected for payment.
Services provided to a patient without proper authorization or that are not
covered by a current authorization are marked as an unauthorized service.
Patients may be billed for uncovered for non-covered procedures, but not
for unauthorized services.
3. Procedure codes are cross-matched with the diagnosis codes to ensure the
medical necessity of all services provided. Any service that is considered
not “medically necessary” for the submitted diagnosis code may be rejected.
4. The claim is checked against common data file. The information
presented on each claim is checked against the insurer’s common data file,
which is an abstract of all recent claims filed on each patient. This step
determines whether the patient is receiving concurrent care for the same
condition by more than one provider. This function further identifies
services that are related to recent surgeries, hospitalizations, or liability
coverage's.
 CLAIM ADJUDICATION –
Cont.
5. A determination is made by “allowed charges”. If no irregularity or
inconsistency is found on the claim, the allowed charge for each covered
procedure is determined. (The allowed charges is the maximum amount
the insurance company will pay for each procedure or service,
according to the patient’s policy. The exact amount allowed varies
according the the contract and is less than than or equal to the fee
charged by the provider, Payment is never greater than the fee
submitted by the provider).
6. Determination of patient’s annual deductible obligation is made. (The
deductible is the total amount of covered out-of-pocket medical
expenses a policyholder must incur each year before to insurance
company is obligated to pay any benefits)
7. The co-payment or co-insurance requirement is determined.
 CLAIM ADJUDICATION –
Cont.
8. The Explanation of Benefits (EOB) is completed. The (EOB) form or
report is a statement telling the patient or provider how the insurance
company determined its share of the reimbursement. The report includes
the following:
a). A list of all procedures and charges submitted on the claim form.
b). A list of any procedure submitted but not considered a benefit of the
policy.
c). A list of all the allowed charges for each covered procedures.
d). The amount of the patient deductible, if any, subtracted from the total
allowed charges.
e). The patient’s financial responsibility for cost sharing (co-payment for
this claim.
f).The total amount payable by the insurance company on this claim.
 CLAIM ADJUDICATION –
Cont.
9. EOB and benefit check is mailed. If the claim form stated that direct
payment should be made to the physician, the reimbursement check and a
copy of the EOB will be mailed to the physician. This can be accomplished
in one of three ways:

a). The patient signs the Authorization of Benefits Statement, Block 13 on

the CMS – 1500 form.
b). The Physician marks “YES” in Block 27 on the CMS – 1500 form.
c). The Physician has signed an agreement with the insurer for direct
payment of all claims.

If reimbursement is to be sent to the patient, the policyholder will received a

copy of the EOB; explanation is sent to the provider by most carriers,
without payment.
 PAYMENTS

PAYMENTS: Amount paid to the physicians against the services rendered by

them to the patient.

THE SERVICES THAT ARE PROVIDED TO THE PATIENTS ARE SENT OUT TO THE
INSURANCE COMPANIES IN THE FORM OF CLAIMS. THESE CLAIMS GET PAID BY THE
INSURANCE COMPANIES. THE PAYMENTS ARE RECEIVED AT THE PROVIDER’S
MAILING ADDRESSES AND / OR AT THE BILLING COMPANIES’ ADDRESSES. IN CASES
WHEN THEY ARE RECEIVED AT THE PROFIDERS’ ADDRESSES THEN THEY ARE IN TURN
FORWARDED TO THE BILLING COMPANY TO THE PAYMENT IN THEIR SYSTEM. SUCH
PAYMENTS COME IN THE THE FORM OF BATCHES AND MAY HAVE BANK’S DEPOSIT
SLIP OR PAYMENT LISTING WITH THEM. PAYMENTS THAT ARE RECEIVED DIRECTLY
AT THE BILLING COMPANIES’ ADDRESS DO NOT HAVE THE BANK’S DEPOSIT SLIP.

SOMETIMES, IN THE CASE OF NON-PARTICIPATING PROVIDER’S, PAYMENTS ARE

RECEIVED BY THE INSURED PARTIES ADDRESS AND THEY FORWARD THE PAYMENT
TO THE PHYSICIAN’S ADDRESS.
 DENIALS
Claim that do not get paid, come back as Denials from the Insurance
carriers. This can be due to posting errors, incorrect procedure / diagnosis
codes, lack of information (medical records) while filing the claims, or
missing / incomplete patient details.

Denials are broken down into two categories: In-House and Patient
Responsibility.
In-House denials are the ones that require some type of correction from our
part and can be resubmitted. We do not bill patient.
Patient Responsibilities are those denials that we can’t do anything to get
the claim paid by the insurance company. Al we can do is, transfer the
charge to the patient with the correct message code.
 A/R MANAGEMENT
The following guidelines are intended to assist staff who are engaged in
Third Party or self follow-up. The guidelines are consistent with the
Fair Debt Collection Practices Act. It is important for the billing
service, as a third party involved in the billing and collection of our
client’s accounts, to confirm our guidelines to the Act to the assure
the protection of the billing service and it’s clients.
CAUTIONARY GUIDELINES
Before placing a follow-up call:
1. Review Insurance A/R aging report.
2. First focus on accounts with aging 120+ days and large balances, You’re your
way down up to 45 days of balance outstanding.
3. For Self-Pay patients, after one statement has gone out, F/U should be done
after 30 Days from the date statement was mailed.
4. Review account notes and transaction history. Make sure that the billing
service is not at fault.
5. Plan what you want to say before making a call.
 A/R MANAGEMENT – cont.

When making Call:

1. Call between 8:00 am. and 9:00 pm. (US Time)
2. Know whom you are speaking to.
3. Identify yourself properly – do not represent yourself as calling from the Doctor’s office.
You are a third party billing service (e.g. Hello, my name is ___________. I am calling
from ___________ (billing service name). We are the billing service for Dr. ___________.)
4. Do not leave messages on voice mail or on answering machines that imply a problem with
an account or any confidential information – you do not know who will retrieve the
message. General messages to return your call is permissible.
5. When need arises to threaten a guarantor with the collection, you should always say : “We
may refer your account to a collection agency or to an attorney for further collection
action.” It is important to remember that any threatened collection action must be taken if
there is no change in account circumstances. Not all clients will transfer account to
collection, please refer to client profile before threatening with taking such action.
6. If the debtor states that an attorney is handling his debts – refrain from any future contact
with the debtor and direct all communications to the attorney.
MEDICAL BILLING FLOW
CHART
THE END