Medical Billing: What Is It?

The process of creating medical claims to submit to insurance companies in order to get reimbursement for medical coding services provided by providers and provider groups is known as medical billing. The medical biller tracks the claim after converting a healthcare service into a billing claim to make sure the organization is paid for the work the provider completed. A skilled medical biller can boost revenue generation for the doctor's office or healthcare facility.

Is medical billing and coding the same thing?

Medical billing and coding are two separate but connected processes. Both are essential to the healthcare industry since they are involved in informing commercial and government payers like Aetna and Medicare about diagnosis, treatments, and supplies.

Medical coders and billers must understand medical terminology, anatomy, and pathophysiology in order to comprehend physician notes and surgical reports because they collaborate with clinical staff. Medical coders can work for billing companies and occasionally take part in billing. It's not unusual for the same person to work as both a medical coder and a medical biller in small physician offices. Although billing and coding are not the same, they both play crucial roles in the healthcare revenue cycle.

The Work of Medical Coders

Every time a patient encounters a physician for medical treatment or evaluation, a medical record is kept. Medical coders go over the patient record and extract information that can be billed, which they then convert into standardized codes.

Procedure codes, such as CPT®, HCPCS Level II, or ICD-10-PCS, inform the payer of the service that was rendered by the healthcare practitioner. ICD-10-CM diagnosis codes provide the payer with information about the patient's reason for receiving the services.

The standardized codes that medical billers currently use to produce insurance claims and bills for patients are where medical coding and medical billing collide.

The medical billing cycle, however, starts before medical coding and doesn't finish until the doctor or healthcare facility has received all reimbursements due for the medical care provided.

The Work of Medical Billers

Medical billers coordinate payments for healthcare services with patients, healthcare providers, and insurance companies (also known as payers). Billers first gather the required data. This contains the patient's demographics, medical background, insurance status, and the treatments or services they have had.

Billers must check patients' medical records and insurance policies to ensure that the treatments are covered in order to collect this data. They produce medical claims next, ensure their accuracy, and submit them to payers. The claims are returned to billers with the agreed-upon payment once payers have approved them.

Before patients see the doctor, billers are currently preparing the patient's bill. This entails subtracting the portion of the surgery or service that is paid for by insurance, accounting for copays and deductibles, and adding any unpaid patient balances. Patients receive invoices as necessary, and payments are posted and reconciled. But there is a lot more that goes on before, after, and in between the medical biller's working hours.

The Method of Medical Billing

Although there are several steps in the medical billing cycle that might take a few days to many months, the top priorities are accurate billing and prompt follow-up. The majority of states mandate that insurance companies settle claims in 30 or 45 days. On the other hand, payers establish claim submission deadlines that, if missed, void coverage. Without the chance to appeal, the late claim is rejected, and the organization is not entitled to compensation.

Medical billers should be able to control their involvement in the billing process since errors can be costly in terms of lost income and increased administrative work at any point in the billing cycle. The efficiency of front-end and back-end billing employees is crucial to the financial stability of physician practices and provider organizations, including hospitals, health systems, and surgery centers.

Medical Billing: Front-End vs. Back-End

The front-end and back-end phases of the medical billing process can be divided into stages. Before the patient meets the doctor, or prior to pre-service billing, occurs. All patient-facing tasks that are necessary for appropriate billing are performed during this phase, which includes the front office staff.

After the patient has seen the physician, back-end billing takes place. The billing process resumes in the back office, which essentially implies that back-end activities are not patient-facing, once the medical coder has finished their duties and the billing team has access to the medical codes that represent the patient interaction.

Workers in the back-end billing department handle the numerous duties related to claims handling and reimbursement as it's the same for a dental billing company. These processes, where straightforward mistakes frequently increase claim denial rate

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, are just as important to revenue cycle management as front-end billing activities. But back-end billing becomes increasingly difficult. All stages of the billing process require certified professional billers, but claim preparation and post-adjudication activities highlight the training and experience needed for this line of work.

Medical Front-End Billing

Staff that handle front-end medical billing should be knowledgeable about the payer mix used by their company. Billers are better equipped to verify insurance eligibility, stay on top of filing deadlines, and know which payers want preauthorization of services when they are familiar with the many payers and health plans that the organization accepts.

Registration as well as Pre-Registration

When a patient makes an appointment with the provider's office or registers at the hospital, the processing of their insurance claim gets started. When a patient arrives at the location of service, staff often asks for their demographic and insurance information, or the patient fills out a registration form.

The billing team is better able to prevent data capture errors when they maintain standard operating procedures for patient registration. When evaluating a patient's eligibility, benefits, and securing prior permission, accurate patient data is crucial.