Medical Billing

“Medical billing” typically refers to the process that starts after a patient is “seen”* and the physician has signed off on the “paperwork”. At this point, the information in the chart is complete and can trigger the billing, using a combination of CPT and ICD-9 codes (sometimes other codes are required, e.g. HCPCS). Usually the physician or a coder in the office determines the codes. However, anesthesiologists, radiologists, pathologists, and surgery centers frequently have this work done by their third-party medical billing company. Professional billing companies, like AHS, use CPC-certified coders.

Of course, the billing process really begins well before this point. That is because patient information, referred to as “demographics” is essential to the medical billing process. This includes insurance information. Historically, the error rate of demographic information entering the billing process has been high, though this is beginning to change where practices use electronic eligibility checks and other workflow improvements.

Medical billing software

Once the “charge” (CPT, ICD, etc.) and “demographic” information enters the billing process, a claim is created and submitted to the appropriate insurance company, referred to as a “payer” or “payor”. Modern billing software, like AHS Virtual Manager, performs numerous edits and “scrubbing” before a claim is submitted. This reduces errors and prevents delays in collecting from the payer (insurance company). At AHS, for example, over 99% of claims are accepted by payers on the first pass.

Medical claims transactions are sometimes referred to as “EDI” since they are a class of ANSI Electronic Data Interchange standards. For instance, an initial claim filing is an “837″ and a payment is an “835″.

When a claim is paid, it is posted; this is done electronically where 835′s are received electronically, a so-called ERA or electronic remittance advice. At this point, the medical billing process becomes much more complex . In many cases, a secondary claim may now be filed, as for Medicare gap insurance. Or the patient may owe a balance that must be billed and collected.

Denial Management and A/R Management

A significant portion of claims require special attention. If a claim is denied by the payer, it must be immediately addressed. Sometimes it is a simple matter of correcting an insurance number. In other cases, additional documentation is required. More complex cases require conversations with the payer which can frequently result in having the claim paid. This is the area where very well run practices, centers, and professional medical billing companies set themselves apart. Without daily attention by skilled staff, denials accumulate, reducing collections (revenue).

Medical Billing Information and Reporting

An often overlooked part of medical billing is information and reporting. Since the billing process represents the entire top line of the practice or center, it is critical that managing physicians and senior administrators have a daily “pulse”. AHS provides its clients with current, daily views of charges, collections, adjustments, and Accounts Receivable. Other AHS reports highlight physician and center productivity and other non-financial measures.

As a final point, it is worth pointing out that the medical billing process provides and requires frequent two-way dialogue with physicians and other providers. Obvious issues include documentation that supports the charges submitted. The oft-repeated slogan is, “If it isn’t documented (in the chart), it didn’t happen.” One important dimension of this feedback is regulatory compliance. It goes without saying that physicians deal in a highly regulated environment and medical billing is no different. The rules and regulations are complex and constantly changing. Well-run medical billing companies operate using the OIG guidelines for third-party medical billing companies.

* Radiologists and pathologists typically see a film, slide or their electronic equivalent rather than seeing the patient directly. In their case, billing begins when their report is completed.

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