What Is The Medical Billing Process?

July 22, 2021
by Admin

What’s A Medical Billing…AKA How Does Medical Billing Work?

Medical billing isn’t sexy. In fact, it’s complicated and confusing…just like your ex. We wish we could just loan you John (seriously we need a few days away from him…volunteers?)…but hey, billing is a necessary evil in the medical industry today…and I guess job security? Either way, we’ve got you covered!

Billing for every medical claim requires too many steps and far too many rules. It’s overly complex and not a ton of fun. Ever wonder why you don’t see too many MDs billing for themselves? Yeah, that’s the no fun and too much time part. Speaking of time, want to save some? Hire John and his team…or feel free to read along…whatever.

Anyhoo, if you want to focus on your practice, it’s best to hand the billing over to an expert team…some nerds who actually like this complex junk and/or have pent up angst they like to take out on the nasties at BlueCross BlueBum, UnitedHeriticsCompany, Enigma and the rest of the crooks. Seriously, we can get our jollies in billing. Yelling at Comcast (pardon, Xfinity) just doesn’t do it for us anymore.


So what exactly do your billing wizkids do so you don’t have too? Let us elucidate the black hole your superbills get sucked into (and hopefully spat back out as checks). Here is what’s involved in the billing process:

Patient Registration

First off, know who you’re working with. Patient registration is the first and one of the most important steps of the medical billing process. Avoid delays and mix-ups. Get the right info from each patient from the jump, and bill the right company for each claim…or don’t and wait 30 days and start over…because hey who likes getting paid right away?

Medical Coding

Did you ever use a vending machine and accidentally punch in the code for veggie chips instead of a Snickers? SUPER disappointing. Punching in the wrong codes for a medical claim is like reaching in the bottom of that machine and pulling out veggie straws, except you might not get your paycheck on Friday and Medicare might come at you for 10K/10yrs in the pen (seriously…that’s the max per claim…oh and if Medicare makes a mistake and you don’t catch them…yeah they call that fraud on your part…totally makes sense). They even keep a public, publicized naughty list so you can see who ordered the veggie chips by accident!

Not sure what codes to use? AAPC has a slick little tool called Codify. It updates annually/automatically and is pretty darn cost-effective. Or you can buy the books and kill a tree. Or you can hire a killer biller…

Charge Entry

This is where your biller’s eyes roll in the back of their heads and all the magic happens. CPT + ICD-10 + modifier validation. Scrubbing for the presence of referring MD NPI. Validating location and fee schedule. Easy step to skip…hugely important step to quality check. All the software programs say they automate it…and they automate the population of data, but you need a human to validate that it makes sense. Skip this step and you’ll see your rejections and denials skyrocket.

Claim Submission

Woohoo! You’re ready to submit your claim to insurance, either electronically or through mail. t. The majority of billing is done electronically unless you’re a dinosaur, but sometimes a third-party liability company or small medical insurance company will require paper claims. Say it with me folks…more electronic, more better.

Payment Review

When your payment is returned for claims, it goes through a review (or it should). This is where your biller goes on autopilot and presses the “auto-post” button. Not ours though. We look at WHAT you’re paid. Was it a bilateral procedure and therefore 150% of the alloable? Did the insurance imbeciles properly apply the multiple surgery reduction of 100%, 50% 25% + for primary, secondary and tertiary+ line items? Are they even accessing the proper fee schedules?

NOTE TO ALL PROVIDERS: Do you have your contracts? No? Guess what? Neither does your billing company then. So how exactly are they validating that you’re paid appropriately then…

Food for thought.

Payment Posting

OK, we’re rounding the bend…home stretch. Payment posting is the deposit and reconciling process that balances the books. You’re biller should be taking that check for 27 patients and distributing it to the proper patient ledgers in your amazing practice management system that you love so much. If your billers are not billing in your system, you should be asking yourself WHY? Does it make your life easier? Is it more efficient for you? Does it give you control of your data? NEWSFLASH: the answer is no.

Denials, Nonpayment, and Appeals

This is why your biller is losing hair/sleep/sanity and why you have hired a biller. 

Denials: AKA, what happens when the claim is not paid. Why? Well, could be missing patient information, incorrect coding, another primary insurance that should be billed first, or incorrect charges for services billed. There are lots of reasons for common denials. OR it could be some bogus reason that masquerades as something it is not to delay payment because that’s the game folks – block/tackle.

Nonpayment: This is bill limbo… the claim hasn’t been denied, but it’s still unpaid. Nonpayment is where you track the unpaid bills. Your biller should be checking every month…on every claim. Limbo is not a good place for your money. The Bermuda triangle did not eat your bill. Someone should be calling on these.

Appeals: If you’re dealing with denials and nonpayment, but you realize the error and correct it, you can appeal the decision. What is the most common appeal you ask? “Dear insurance dingbat, did you read what we last sent you? Here it is again. Please concentrate on the stuff we underlined, not highlighted because we know when we highlight you claim that you can’t read it when you scan it in on your black/white scanners from 1995 that operate on an MS-DOS system you neanderthals.”

Patient Statement Submission

Hold up, what step are we on? Eight? Ten? Well, whatever it is, you can now bill your patient.

The patient statement is the billed total that is sent to a patient for copayment. This might also include bills that are not covered by insurance or for the amount that is their annual co-insurance. This is typically what is left over after insurance has paid.

Are you sending paper statements still? Those went out in the 90s with Binaca and Jnco Jeans. Make sure your biller is making it stupid simple for your patients to pay with some shiny new tech. Seriously…you’ll see 30% more payments.

Patient Billing Inquiry

Once you send out the bill, your patient will be calling with questions. You know how everyone is disenfranchised with our horrifying healthcare system. Yeah they call us with the questions. Make sure your biller and/or billing company actually picks up the phone. We’ve got a 90% answer rate (pats self on back). Guess what…we still get daily complaints because Jane Doe likes to cycle call 3x and hang up when the phone isn’t answered in 13.5 seconds and then calls you to tell you no one picks up. #ReasonsWeRecordCalls&TrackLogs. All joking aside, expect complaints…it’s how people get out of paying bills whether they’re justified or otherwise.

Make Medical Billing Easier

So. That was a lot. Good news is, it doesn’t have to be. Hire a solutions company to help you manage these processes.

We can make this a lot easier. If you’re worried about how to handle your medical billing processes with accuracy and consistency, call us, this is what we do.

You focus on running your practice. Let us do the complicated, confusing, unsexy stuff.




Share: Share this article on LinkedIn Share this article via email