How to Track Your Claim from Submission to Payment in Medical Billing - dummies

How to Track Your Claim from Submission to Payment in Medical Billing

As a medical billing professional, your claim will take a (potentially arduous) journey on the path from submission to payment. The claims process begins when you enter the CPT and ICD-9 codes into the billing software, but it certainly doesn’t end there. Of course, not all submissions have happy endings; they get stuck along the way. In that case, you need to file an appeal.

Everything that happens in the claims process is reliant on the software you use to code. Consider this software the backbone of what you do. It prepares the claim to be submitted to the claims clearinghouse.

Features of the software

Many different types of billing software are available, but they all allow you to enter the procedure codes and diagnosis codes, as well as the provider’s fee for each code, the patient’s insurance information (policy number and group number), and the payer’s address. The software also links each payer to a specific payer ID.

Most of the newer versions of billing software are compatible with electronic medical records (EMRs), in which case the billing modules of the software are included with the clinical modules of the patient’s record. What this means is that the clinical staff clinical enters the clinical information and provides additional documentation of medical necessity.

Here are some other features you may encounter:

  • Some offices use billing software that links into their electronic medical records, while other offices have encounter-specific information (encounter times, names of clinical staff involved in the encounter, and so on) stored in the billing software. This information is useful for inventory purposes, to determine the cost of each patient’s care, and in the event of any legal inquiries.

  • Some offices have security edits in place that allow access to various parts of this software based on the employee’s need to know or clearance. Access to the patient’s personal history, for example, may not be viewable by the billing staff, and access to patient demographic information, such as Social Security number, may not be viewable by the charge-nurse.

Numerous types of billing software systems are available, and the one you use depends on the provider’s needs and budget, but the primary purpose of all billing software is to serve as a platform to prepare the claim to begin its journey, which ends when the provider receives payment from the insurance company or other payer.

Make sure the correct contract is loaded into the billing software

Normally, payer contracts are already loaded into the office billing software so that, when you enter information, the software automatically links each procedure to the appropriate payment obligated by the payer contract.

Having the correct contract loaded saves time because it facilitates payment posting on the back end of the claim. Here’s why: When the insurance company makes a payment, the payment is posted to each patient account. The person responsible for posting payments is referred to as the payment poster. If the contract isn’t loaded correctly, the payment poster must verify each payment to make sure that it’s correct.

In small companies, the payment poster may be the office manager or other front office associate. Larger companies, including most billing companies, have employees whose job is limited to just posting payments to the correct accounts.