Medical Billing Services 101

“Medical Billing Servicesâ€� typically refer to the product and service offers from Medical Billing Companies. These services can be described as “outsourced medical billing” although many equate the term outsourcing with work done offshore. This is not necessarily the case, as many medical billing companies do all of their work in the US (like AHS). Medical billing services are sometimes referred to as “practice management”, though that term can also be used to describe a broader set of functions. Medical billing services include

Creating a medical billing claim

Capturing, entering, and editing (“scrubbing�) a wide variety of information is the first step needed to create a medical billing claim (to an insurance company or payer). This includes “demographic� information about the patient including insurance coverage details and “charge� information: a combination of CPT and ICD-9 codes determined by the physician or a coder.

Electronic claims filing

Claims are filed using medical billing software and EDI technology or paper (for the small number of payers who do not accept electronic claims).

Posting payments

Payments and related information, referred to as an EOB: explanation of benefits (returned from the insurance company) generate information that must be entered into the billing system. This includes capturing denials when a claim is not paid. Increasingly, this information is available electronically (via EDI) so that it can be entered into the billing system automatically.

Medical Billing Bank Deposits.

Medical billing companies never receive payments directly from payers or patients but they do deposit paper checks received into their client’s bank accounts. Increasingly, payers are moving to EFT payments, but this trend is far from complete.

Accounts Receivable management.

Monitoring payment intervals from both payers (insurance companies) and patients to assure that payment is made on a timely basis. Industry benchmarks for “Days in A/R� are available from the MGMA, HBMA, and others. This activity also includes analyzing underpaid claims and those that do not match contracted amounts.

Denial Management.

Denials issued by payers are accompanied by a denial code or reason. Follow-up is required by billing staff to resolve the issues identified and to re-submit the claim for payment.

Patient statements and billing.

Patients frequently have a balance due after an insurance company adjudicates a claim. This can be a co-pay, deductible, or other form of “patient responsible� billing.

Collections referral.

Where patient balances remain unpaid after an extended period, typically sixty to ninety days, a practice may ask the medical billing company to refer the account to a Collections Agency.

Reports, statistics, and dashboards.

Medical billing and collections represent in-depth data about the practice’s financial and operational health. As a result, timely and insightful reporting helps physicians and practice managers improve their daily operations.

Medical billing software

Billing software is not a direct part of most medical billing services. However, many electronic billing features are inherent in modern billing services and they are made available to practices where needed. For example, scheduling software including demographic information capture or electronic charge capture. Electronic medical records (EMR) or electronic health records (EHR) can also be included as an extra cost feature.

Interfaces.

Many practices have existing systems with information needed for the billing process. This is particularly true of hospital-based practices where demographic information is resident in hospital registration systems (so-called ADT information: Admit, Discharge, Transfer). Other examples are RIS and PACS systems in radiology practices, laboratory systems in pathology practices, and EMR / EHR systems in other practices.

Of course, all of these components must fit together into a cohesive “end to end” medical billing solution for each practice served.

 

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