How Medical Billing Services Work

Going to the doctor may seem like a one-to-one interaction, but in reality it’s part of a large, complex system of information and payment. While the insured patient may only have direct interaction with one person or healthcare provider, that check-up is actually part of a three-party system.

 

The first party is the patient. The second party is the healthcare provider. The term ‘provider’ includes hospital, physicians, physical therapists, emergency rooms, outpatient facilities, and any other place where medical services are performed. The third and final party is the insurance company, or payer.

 

It’s the medical biller’s job to negotiate and arrange for payment between these three parties. Specifically, the biller ensures that the healthcare provider is compensated for their services by billing both patients and payers. We bill because healthcare providers need to be compensated for the services they perform.

 

Here’s a quick look at the day-to-day activities of a professional medical biller.

 

Working with Patients

• When a patient receives medical services from a healthcare provider, they’re typically presented with a bill at the end of their services. The biller creates this bill by looking at the balance (if any) the patient has, adding the cost of the procedure or service to that balance, deducting the amount covered by insurance, and factoring in a patient’s copay or deductible.

 

• Billers also work daily with a patient’s medical records. Where coders use medical reports to accurately translate medical services into code, billers abstract information from patients’ medical records and insurance plans to create accurate medical bills.

Working with Computers

• Today, almost every doctor’s office in the country uses some form of practice management software. This software keeps track of patients, helps schedule visits, stores important medical information and generally helps the practice run smoothly.

Creating Claims

• The majority of a medical biller’s day is spent creating and processing medical claims. Billers need to be familiar with what type of claim an insurance payer accepts, and adjust their claim creation accordingly. Billers may also work frequently with insurance clearinghouses to streamline the claims process.

 

• Billers also have to check that each claim is compliant. Ideally, every claim a biller sends out will be “clean.” A clean claim contains no errors, and will be processed speedily by the payer, ensuring that the healthcare provider gets reimbursed quickly and efficiently.

Notification and Communication

• A biller is constantly in communication with insurance payers, clearinghouses, providers, and patients. Since the biller acts as the waypoint for the reimbursement process, they frequently have to clarify and follow-up with all parties of the healthcare process.

 

• Billers also explain and notify patients of their bill. Billers are in charge of issuing Explanations of Benefits (EOBs) to patients, which list which procedures are covered by the payer and why.
• Billers must also follow up with patients about paying the balance on their medical bills.

Collections

• In the case of a patient with delinquent bills, a medical billing specialist may have to arrange for collections on that debt. This is not necessarily a “day-to-day” activity, as one would hope that a provider’s patients were not ignoring their medical bills on a daily basis, but it is something to be aware of.

For the original article click here: https://www.medicalbillingandcoding.org/introduction-to-billing/