subject: Medical Billing Process [print this page] Medical billing and coding is a procedure of submitting and following up on claims to insurance companies to receive payment for services and amenities offered by a health care provider. This exact process or any similar procedure is carried out for most insurance companies, whether if they are government owned or private companies. Even though not required by law, medical billing personnel are encouraged to take examinations such as CMRS, RHIA, and others to gain certification. Schools that issue certifications provide theoretical background for students entering the field of medical billing.
The medical billing process is an indirect interaction between a health care provider and the insurance company. This interaction is entirely known as the billing cycle. This can take from a few days to several months for completion, and need numerous repetition of process before an agreement is reached. The deal starts with the office visit. A patients medical record is created or updated by the doctor. Then, diagnoses are done to the patient to determine the specific the health care services that will be rendered. The patient record will hold information collated from the diagnoses, such as nature of illness, examination details medication lists, and suggested treatment.
The scope of the physical diagnoses, the complexity of the medical decision-making and the history acquired from the patient are examined to determine the proper services that will be used to bill the insurance. The degree of service, once found out by qualified health care personnel, is translated into standardized medical codes from processing claims.
Once the health care services are determined, medical billing companies will transfer the claim to the insurance company. To date, this is typically carried out electronically by setting up the claim as a secured ANSI 837 file and utilizing Electronic Data Interchange to submit the claim file straight to the insurance company or through a clearing house.
The insurance company then processes the claims from medical billing companies by medical claims examiners or adjusters. For higher amounts of claims, the insurance company conducts a review on claims done by a board of medical directors and examines their validity and eligibility.
If medical billing companies receive rejection messages, they must be deciphered, reconcile it with the original claims, make required modifications and resubmit the claims until the claims are approved.
