Healthcare is available to everyone, but those who have the ability to pay can sometimes get better healthcare than those who do not have the ability to pay. This can vary from country to country and can even vary within states and provinces within a country.
The term medical billing refers to the process of submitting, following up and paying for claims with health insurance companies. The same process is generally used regardless of whether the medical facility or physician is private or government sponsored.
Not everyone can get a job as a medical biller. Many physicians billing service require the biller to become certified in a specific exam like RHIA , CMRS or even other exams. This isn’t a requirement by law. This means it isn’t illegal for a company to hire a biller who doesn’t have this type of certification. Still, many companies prefer their billers to have those designations mostly because the additional training give students an added edge by providing coveted theoretical grounding for students who want to enter the field of medical billing.
The Process of Physician or Medical Billing
Medical or physician billing is the process used to describe the interactions between the payer (which can be the insurance company or the client directly) and the physician or other healthcare provider. The entire process can be as fast as a few days but can take as long as several months to complete. Sometimes several interactions are required before any type of resolution can be reached. The more complicated the billing process.
The interaction for the billing process begins with the office visit where the physician or the physician’s stall accesses and updates the patient’s medical records. Once this is done, diagnosis and procedure codes are assigned. These codes are consistent across the board and have been regulated that way to make reading the billing process easier and more efficient. It maximizes billing clarity.
After the codes have been deciphered, they’re sent to the medical billing service that enters the information into the system and sends the claim to the insurance company. This used to be done manually with paper but with the increase of digital use, paperless offices and the speed of emails, most information transmission is done electronically. Electronic claims are formatted as an ANSI 837 file.
The claim goes to the medical claims examiners, also known as the medical claims adjusters. The higher the amount of the claim, the closer scrutiny it receives. Higher claims need to be evaluated for validity and patient eligibility, medical necessity and provider credentials are all taken into consideration.
Claims are either accepted, denied or rejected. There is a difference between denied and rejected claims. A denied claim means that the examiners have determined that the claim is not payable after it has been processed. Denied claims can be appealed. A rejected claim means the claim wasn’t process for various reasons, most commonly because there’s a fatal error in the information supplied. An example of a fatal error is when a name and identification number do not match. Rejected claims from a physicians billing service need to redone and resubmitted.
