Aside from providing quality medical care, billing has the greatest impact on a health care practice’s bottom line. But the process is multifaceted, and practices face several challenges when aiming to maximize revenue through effective billing. This guide will help you understand each step of the revenue cycle management process in medical billing and how to enhance efficiency for improved cash flow.
What Is the Medical Billing Process?
To improve your medical billing process and procedures, you need a clear outline of each stage in the workflow. The medical billing process has 12 steps.
1. Patient Registration
Our billing process medical billing process flow chart starts the moment a patient requests your services. For each new patient, you must capture their:
- Medical history.
- Insurance information.
- Personal details.
- Demographic data.
For returning patients, it’s important to update their medical history upon each visit and check that the information you have on file remains current.
2. Determining Financial Responsibility
A patient’s financial responsibility for a procedure varies between insurance carriers and policies, and what a policy does and doesn’t cover sometimes changes from year to year. Keep records of each patient’s coverage plan and update them regularly so you can verify what the patient and carrier will each pay toward a medical bill. Many payers have an online eligibility verification tool you can use to check whether they cover a given procedure. If a patient’s carrier doesn’t have this tool, you may have to contact them directly to clarify details like:
- Eligibility effective dates.
- Patient coinsurance.
- Copayments.
- Deductibles.
Insurers often require preauthorization for procedures outside primary care, so be sure to comply with these requirements before carrying out any procedures.
3. Point-of-Service Collections
If your patient is responsible for a copayment or deductible, aim to collect this at the front desk during check-in or check-out. Point-of-service collection can save time and money on follow-up and reduce the risk of bad debt.
4. Capturing Codes
For compliant medical billing, you must record the correct ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes. The World Health Organization’s ICD codes correspond to symptoms or conditions, while the American Medical Association’s CPT codes correspond to treatments health care providers administer.
Payers reimburse you based on which of the tens of thousands of unique ICD and CPT codes you capture on the bill, so it’s worth investing in a professional coding service and smart software for efficient and accurate coding.
5. Creating the Superbill
The superbill is the primary document for your reimbursement claim. It’s also called an encounter form or fee ticket. Along with your patient and health care provider’s information, it should contain details about the visit, including:
- The visit’s date and duration.
- The relevant CPT and ICD codes.
- Any fees you have charged the patient.
You will use all this information to generate a claim from a third-party payer.
6. Charge Entry
Since medical fees are not standardized, you must specify your charge for the procedure on the superbill. You should also break this down to distinguish any amounts you have charged the patient from the amount the insurer should cover. This prevents you from receiving double reimbursement, which would be a legal and ethical issue.
7. Claim Scrubbing
Before submitting a claim, billers scrub it. Claim scrubbing means checking the claim, either with claim scrubbing software or manually, to ensure all the required information is present and accurate. Important details to check include patient, provider and visit information, especially codes and modifiers.
8. Claims Forms
When you’re ready to submit the claim, ensure you do so using the correct form. If your patient is on Medicare or Medicaid, you’ll need to use one of two forms:
- CMS-1500: You’ll use this form to claim for professional services by physicians and Ambulatory Surgical Centers.
- CMS-1450: This form is also known as the UB-04. You’ll use it to report services at inpatient institutions like hospitals.
Private payers may require you to use their own custom forms, though many accept the CMS forms.
9. Claim Submission
You could submit claims electronically to a payer yourself, though most practices prefer to outsource this step. A reputable outsourced medical billing company has the expertise and resources to improve your first-pass approval rate so you receive more payments in less time.
10. Claim Tracking
After submitting a claim, you must monitor the payer’s adjudication process. After they review your claim, there are three possible outcomes:
- Accepted: The insurer will pay your bill based on the amount your patient’s plan covers.
- Denied: You filed correctly, but the claim did not meet payment criteria. This usually happens when the billed procedure is not eligible under the patient’s plan.
- Rejected: The payer cannot process your claim, usually because of inaccurate or missing information. You may still be able to receive reimbursement if you address these errors and resubmit before the payer’s deadline.
11. Creating Patient Statements
After the payer responds to your claim and pays their share if the procedure is eligible, you must prepare a statement to update your patient about their account. If there are any outstanding fees, this statement should include a request for payment and a clear explanation of how and when they can pay their balance.
12. Following Up
After sending the initial patient statement, consider sending a reminder a few days before the payment deadline if the patient has not yet paid. If they miss the deadline, conduct further follow-up to recover as much revenue as possible. Use multiple communication channels and offer to discuss various payment plans and options to improve your chances of collecting.
How to Improve Your Medical Billing Process
Try these five tips to improve your medical billing process:
- Leverage electronic health records (EHR): EHR make it easy to update patient information and automate claim generation for improved accuracy.
- Track denials: Every time a payer denies or rejects one of your claims, note the reason and aim to address it. Look for trends in denials to ensure you are improving your billing for more first-pass approvals and better cash flow.
- Enhance communication: Your clear, consistent communication helps your patients understand what they owe, why and what payment options are available to them.
- Offer payment options: Creating a seamless payment experience is vital to increasing revenue. Give your customers a range of options, including in-person card and cash payments, mobile card payments, Apple Pay and other secure payment services.
- Outsource your billing: Outsourcing your medical billing to a professional billing company can save you time and resources while improving your first-pass approval rate for increased revenue.
Streamline Your Billing Process With ProMD Medical Billing
Accurate, efficient billing is essential for your medical practice to maintain a healthy bottom line. At ProMD Medical Billing, our AAPC-certified medical billing and coding professionals will create a tailored outsourced billing solution to suit your practice. While your practice focuses on excellence in health care, we work to increase your revenue through industry-leading claims submission, denial management and payer follow-up services. After just 90 days with ProMD, you could see a 20% revenue increase.
Contact us to learn more about how our medical billing services can help your practice.
ProMD Medical Billing is happy to help with your billing assessment needs so you can maximize profits and increase patient satisfaction. To learn more about how ProMD can make your practice run like a well-oiled machine, call (866) 960-9558 or fill out our online form to request a billing assessment.