MEDICAL BILLING

-AN OVERVIEW

Medical Billing - An Overview

 U S HEALTHCARE

Medical Billing Claims Adjudication

Medical Billing is the practice The insurance review

of submitting claims to department reviews the
Insurance companies or the claim and after the edit
United States government, checks, the claim is
specifically Medicare in order adjudicated and
to receive payment for processed for payment.
services provided to a patient The check and the
by a doctor Explanation of Benefits
are sent to the provider

Medical Billing - An Overview

 Difference Between Indian & U S Healthcare
Industry

Indian Healthcare U S Healthcare

• All citizens do not have
medical insurance to cover
their healthcare needs
• Patients have to pay upfront
the total cost before the
services are rendered by the
Doctor
• All citizens have medical
insurance to cover their
healthcare needs.
• Patients do not have to pay
upfront the total cost for the
services to be rendered by
the Doctor.

Medical Billing - An Overview

Billing Process

Medical Billing - An Overview

Billing Process

Medical Billing - An Overview

 Doctor’s Office

 A patient visits the Doctor and gives his/her insurance card.

 Patient fills the patient registration form at the front desk
 Patient then explains his/her problem to the Doctor
 The doctor then diagnoses the ailment and draws a chart explaining
the treatment that needs to be rendered.
 Eg: If the patients complains of frequent headache, a sequence chart
would be drawn by the provider to explain the treatment pattern

Medical Billing - An Overview

Medical Insurance Card

Medical Billing - An Overview

Medical Billing - An Overview
 Scanning

 Demographics, superbills/ charge sheets, insurance verification and

a copy pf the insurance card and any other information pertaining to
the patient, is either sent to the billing office or to our office
 The billing office scans the source documents and saves the image
files to an FTP site or onto their server.
 Our scanning department retrieves the files. The images are split and
arranged according to patient names
 The files are sent to the appropriate departments with the control log
for the number of files and pages received.
 Illegible/missing documents are identified and a mail is sent to the
Billing office for rescanning

Medical Billing - An Overview

Patient Super Bill /Encounter Form

Medical Billing - An Overview

 Coding

 The coding team assigns the Numerical codes for CPT (Current
Procedural Terminology) and the Diagnosis Code based on the
description given by the provider

Medical Billing - An Overview

 Patient Demographics

 In this department, the patients personal information is entered from

the demographic sheets.

Medical Billing - An Overview

 Charge Entry

 In this department, the relationship of the Diagnosis code and CPT is

checked.
 A charge is then created according to the billing rules pertaining to
specific carriers and location.

Medical Billing - An Overview

Charge Entry Screen

Medical Billing - An Overview

 Claims Transmission

 Claims are filed and information sent to the Transmission

department.
 The transmission department prepares a list of claims that go out on
paper and through electronic media.
 Once claims are transmitted electronically, confirmation reports are
obtained and filed after verification
 Paper claims are printed and attachments done, put into envelopes
and sent to the US for postage and mailing.
 Transmission rejections are analyzed and appropriate corrective
action is taken.

Medical Billing - An Overview

 Payment Posting

 The cash team receives the cash files (Check copy & EOB) and applies
the payments in the billing software against the appropriate patient
account.
 During payment posting, overpayment are immediately identified and
necessary refund requests are generated to obtaining approvals
 Under payments/Denials are also informed to the Analysts.

Medical Billing - An Overview

Payment Posting Screen

Medical Billing - An Overview

 Analysis

 AR Analysts are key to any group.

 The claims are researched for completeness and accuracy and
work orders are set up for the call center to make calls
 AR Analysts are responsible for cash collections and resolving all
problems to enable the account to have a clean AR
 They also research the claim denied by the carriers, rejections
received from the clearing house and low payments by the
carriers.
 The analyst reviews for global patterns and bulk problems are
solved at one instance

Medical Billing - An Overview

 AR Follow-up

 This is the hub of activity around which Medical Billing operates.

 The caller will call up the insurance and verify if the claim is with
the carrier and its current status.
 The caller checks whether the claim is being processed for
payment or denial
 Based on the inputs from the caller, the analyst goes to work and
gets the required pre-requisites needed.
 Incase of payment, the analyst would compile a list of payments
details or if denied then corrective action is initiated
 The calling team receives work orders from the analysts and
initiates calls to the insurance companies to establish reasons for
non-payment of the claims.
 All reasons are passed on to the analyst for resolution.

Medical Billing - An Overview

 Month End Reports

 At the end of the month, Doctor Financials, aged summary

reports so that we asses the momentum that has been
achieved this month, and if not see where there is a pattern
of non payment.
 In this way, any bulk pending issues are tackled.
 Any claim beyond the 60 day pending is acted upon, if it is
pending for clarification then that needs to be informed to
the respective account manager at the center so that
remedial steps could be initiated.

Medical Billing - An Overview