How is a Medical Billing Claim Processed?

Claims processing in Medical Billing and Coding refers to the overall work of submitting and following up on claims. When you’re not interfacing with the three Ps — patients, providers, and payers — you’ll be doing the “meat and potatoes” work of your day: coding claims to convert physician- or specialist-performed services into revenue.

Here in a nutshell is the general process of claims submission, which begins almost as soon as the patient enters the provider’s office:

  1. The patient hands over her insurance card and fills out a demographic form at the time of arrival.

    The demographic form includes info such as patient name, date of birth, address, Social Security or driver’s license number, the name of the policyholder, and any additional information about the policyholder if the policyholder is someone other than the patient. At this time, patient also presents a government-issued photo ID so that you can verify that she is actually the insured member.

    Using someone else’s insurance coverage is fraud. So is submitting a claim that misrepresents an encounter. All providers are responsible for verifying patient identity, and they can be held liable for fraud committed in their office.

  2. After the initial paperwork is complete, the patient encounter with the service provider or physician occurs, followed by the provider documenting the billable services.

  3. The coder abstracts the billable codes, based on the physician documentation.

  4. The coding goes to the biller who enters the information into the appropriate claim form in the billing software.

    After the biller enters the coding information into the software, the software sends the claim either directly to the payer or to a clearinghouse, which sends the claim to the appropriate payer for reimbursement.

If everything goes according to plan, and all the moving parts of the billing and coding process work as they should, your claim gets paid, and no follow up is necessary.

Of course, things may not go as planned, and the claim will get hung up somewhere — often for missing or incomplete information — or it may be denied. If either of these happen, you must follow up to discover the problem and then resolve it.

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