How are Claims Filed? A Look at the Medical Billing and Coding Workflow

Understanding how medical bills are processed is important for doctors and patients alike. Although there are slight variations, the medical billing and coding workflow typically follows a similar pattern from start to finish-below is an overview.

Patient Check-in and Checkout

When patients check in to a medical office, the receptionist verifies demographic and insurance information. Upon checkout, medical reports including visit notes are sent to a medical coder, who deciphers the information and translates it into the proper code. Another report known as a “superbill” is then generated containing patient demographic data, the diagnosis codes, procedures performed, and other pertinent information.

The Role of the Medical Biller

Once created, the superbill is transmitted to a medical billing specialist. Next, the superbill will be used to create a paper claim, or information from it will be entered into medical billing software so that an electronic invoice may be generated. Information is then double-checked for accuracy and to ensure that the claim meets the informational requirements of the individual payer.
Once the medical biller is satisfied, he or she then transmits claims, taking care to see that the requirements set forth by the Health Insurance Portability and Accountability Act (HIPAA) are strictly followed. Claims do not automatically go to the payer in most cases, but rather to a clearinghouse that is responsible for collecting them. Clearinghouse personnel are responsible for making sure the formatting requirements of each carrier are strictly adhered to before passing them on to the insurance company.

The Adjudication Process

After an insurance company receives a claim, a process known as adjudication takes place. During adjudication, payers evaluate claims to decide whether or not they are valid, and if so, what percentage of the amount will be paid.

At the end of adjudication, a payer will determine if the claim will be reimbursed for, denied, or rejected. Denied claims are ones that a payer refuses to process for one reason or another. Rejected claims are those that contain some type of error, which may normally be corrected and resubmitted.

A payer sends a written report to the provider detailing the exact terms of payment. A medical billing specialist will review this report to make sure the amount paid matches up with any previously agreed-upon contracts. If there are any discrepancies, an appeal may also be submitted, the scope of which will vary from one insurance carrier to the next.

Follow Up

The follow-up process entails many things, namely:

  • Generating patient statements for any remaining amounts
  • Checking up on payments
  • Collecting past-due balances
  • Keeping up with aged receivables
  • Writing off uncollectable debt

As you can see, there are many phases in the medical billing and coding process, all of which are equally important. If there are problems in even one area, your entire practice could suffer. Here at Leeward Medical, we are familiar with all aspects of medical billing and coding, and will diligently follow through to see that nothing falls through the cracks. For expert help, please contact us.