How Significant are the Innovative Medical Billing and Coding Solutions in Healthcare

How Significant are the Innovative Medical Billing and Coding Solutions in Healthcare


We can easily state that we live in an age that has seen the peak of technology evolution and implementation in nearly every field. Medical science has benefited immensely with all the advancements that has helped to address patient needs correctly, make medical functions more efficient, ensure patient safety, and help healthcare providers to effectively diagnose, treat, and prevent illness.

The days of using traditional methods to deal with patients are long gone, and medical practices have to incorporate robust, reliable, and cost-effective ways to achieve success and sustainability, whether it is employing modern medical equipment, doing extravagant research for new and better medicines, integrating digital technology, or using custom software and solutions to streamline the busy workflow.

The medical services are a few of the assistance needed 24/7 and all year round without any break. Any person getting ill to acute or chronic disease or sustaining any injury requires immediate and quality care to ensure health and well-being. The hospitals and health centers provide timely care and treatment to the incoming patients but must get proper payment for rendering their expert services.

Revenue Cycle Management and Challenges for Medical Practices

Most patients buy medical insurance plans that allow them to get proper medical treatment without worrying about taking loans or having doubts about receiving the required treatment due to financial constraints. On the other hand, the medical practices also require financial resources to survive and sustain, so a medical bill is formed and sent to the respective insurance providers for collection of payments and reimbursement of healthcare providers.

Medical revenue cycle management (RCM) is critical in ensuring that the medical practices and health centers get financial resources to timely pay wages to healthcare providers and pay for medical supplies, equipment, and make other necessary payments.

Medical practices and healthcare centers rely heavily on healthcare billing systems and insurance providers for funding. On the other hand, insurance companies get money by charging people who buy insurance plans and pay monthly fees and premiums.

Healthcare cost increases with the aging population that requires pertinent care, and due to Coronavirus pandemic that has added significant burden and pressure for health centers to operate efficiently. The growing list of challenges that medical practices as a whole face are

  • Increasing patient number
  • Delivery of quality healthcare services
  • Inefficiencies in different administrative procedures and systems
  • Time management
  • Recruiting qualified and diligent healthcare practitioners and support staff
  • Compliance with healthcare policies
  • Relationships with third-party payers
  • Maintaining a smooth revenue management cycle
  • Coping with liability issues

The Importance of Medical Billing and Coding

The two components that hold the key to effectively manage a medical practice’s revenue cycle are ‘medical coding’ and ‘medical billing.’ Medical coding involves giving alpha-numeric codes to all the diagnosis and treatments that a patient receives from the moment an appointment is scheduled.

Medical billing is a claim based on medical codes and sent by medical practice to an insurance company for proper reimbursement for the facilities and services given to the patient.

If you happen to overhear the conversation in medical/nursing home on what pushed a person to become a doctor, then most answers would revolve around

  • I want to help and take care of people
  • I wanted to be in the medical profession since I grew up
  • I would research and find a better cure for ailments
  • I want to play my part and make the world a better place

But you will not hear anyone saying he/she want to take part in administrative duties and track through all the complicated and challenging medical billing and coding. A medical practitioner's primary job is to ensure the health of the patients, and not spend hours and hours in manual paperwork.

Thankfully, due to technological advancements, nearly all the medical professionals, from physicians to support staff, do not have to do mundane paperwork and use innovative solutions and software to perform and complete a task. The sophisticated software solutions have automated the entire administrative and RCM process and altered how a medical practice interacts with both patients and insurance providers.

How Medical Billing Software help a Medical Practice

The medical billing and coding software allows medical practices, hospitals, and even physicians clinics to streamline their revenue cycle and ensure timely collection of payments. Medical billing software is a computer application that automates the coding and billing process, but a medical practice must ensure that the medical billing software

  • Include Patient Pre-registration

The first step is to register all the patients and then check for insurance eligibility and status. Importing or writing patient information can be tiresome and challenging. Once a patient’s details are entered and saved, the front end staff do not have to ask or fill in the details whenever patients come back for diagnosis or treatment.

  • Help with accurate medical claims processing

The medical practice needs constant financial resources to provide the services, and it can only be possible if the medical claims are processed correctly. The insurance companies are very meticulous in their scrutiny and reject any claims based on inaccurate coding and billing. The medical claim is based on all the diagnosis, treatments, and medications that the patient receives to regain health.

As there are numerous patients with insurance from different companies, so it can be difficult for a medical practice to manage and comply with specific insurance company’s policies to get full payment.

  • Provide valuable financial management and accounting services

Financial management is a complex task in any field, and in the medical field, the right software can help a medical practice handle all the important financial tasks such as payroll, accounts payable and receivable, online bill pay, and any outstanding payments.

  • Organizes all the coding, billing, and collection tasks

The medical billing software will help know the eligibility of patients' insurance plans and remind them of the costs that the insurance company will cover and the cost that the patients have to pay on their own. The software helps to track and manage all the collections and also pursue denied or rejected claims.

  • Enable value-added features such as scheduling, reporting, and storing patient information

One of the prime advantages of installing medical billing software is its ability to integrate with the hospital management system and EHR (Electronic Health Records). The patient records and information is stored in one centralized location.

Another advantage is scheduling patients' appointments as every patient may want to come to the hospital or clinic for different illnesses. The scheduling process is crucial for patients who come for diagnosis and may return for treatment purposes.

The innovative software solutions have allowed medical practices to set key performance indicators (KPIs), review weekly and monthly performances, and analyze the revenue flow. Modern medical billing software solutions are equipped with features such as generating custom reports such as patient history, financial reports, workflows, alerts, and notifications.

  • Help with HIPAA Compliance

For every medical practice, the essential task is to keep up to date with HIPAA (Health Insurance Portability and Accountability Act) compliance standards, as any delay can lead up to lawsuits and monetary penalty.

A medical practice's success at getting full payment of the services rendered to patients lies mostly in medical coding as each diagnosis, medications, and surgical procedure accounts for a particular code. The conversion of diagnosis and treatment allows the medical practice to process the bill accurately.

Why Medical Coding is Core Feature of Billing Software

The common codes that become part of a medical bill include CPT (Current Procedural Terminology) codes and ICD (International Classification of Disease) codes. Currently, the tenth edition or ICD-10 is used in the medical industry. The ICD-10 codes are made by World Health Organization (WHO) and necessary to maintain patient records and medical billing process.

The sophisticated coding and billing solutions relieves the manual tasks of coding as all the codes are predefined, and the coding specialist only needs to select the code instead of memorizing or keeping track of all the complex codes. Once the coding is done, the software also helps the administrative team to

  • Follow up on claims
  • Resolve issues with denied claims and resubmitting them
  • Posting payments and managing collections

It is a known fact that more than 50% of medical claims are denied or rejected by the insurance company due to errors in coding and billing, and in many cases, the payment is denied as the medical services given to patients are not covered in the insurance policy. The medical billing cycle steps include

  • The front desk of medical practice will use the software to check the patient’s insurance eligibility while scheduling an appointment
  • An automatic reminder is activated to reduce no shows.
  • When the doctor meets the patient, information from the EHR is generated and sent to the billing software to ensure communication from the front desk to the healthcare provider
  • The codes are selected based on the diagnosis or treatment, and then a bill is submitted to the insurance company. A value-added feature of ‘scrubbing’ ensures that claims meet the requirement and are accepted without any objection.
  • Most of the billing criteria are payer-specific, so it is important to verify the payer’s claim submission guidelines.

The digital solutions and systems are imperative in the healthcare sector and more so with the Covid-19 outbreak that has put an extra burden on medical practices to care for the patients diagnosed with Coronavirus and patients wanting treatment of acute or chronic ailments. Faster and accurate claim processing gives more control and flexibility to the medical practice.

Most healthcare centers focus primarily on patient care but streamlining the financial and revenue cycle is necessary to make sure that the patient's needs concerning medications or any procedural treatment are effectively met. Implementing a robust and advanced billing and coding software will improve patient satisfaction, lower operational expenses, reduce claim denials, and increase cash flow.