An efficient and robust healthcare system is based on few key elements that include the various health providers, the administrative staff, medical equipment and machines, medicines and drugs used for treatment of diseases, and insurance companies. A medical practice needs proper financial resources to ensure not only the delivery of medical services to the patients but payment to the health providers and support staff, and also payment of overheads.
The Significance of Revenue Cycle in Medical Practice:
‘Revenue Cycle Management’ is essential to streamline the tasks and allow the medical practice to run smoothly. A sophisticated management software is needed to automate key functions such as scheduling, medical billing and coding, claim submission to insurance companies and collection of payments. One small mistake in entering right patient details or assigning incorrect codes can disturb the revenue flow of a medical practice.
Most people buy health insurance, which allows them to cover for the expensive medical bills, which can be tough for anyone who is going through financial constraints. Health insurance companies offer different plans according to the type of diseases and the estimated amount that will be served on the treatment.
Medical practices such as hospitals and health centers rely on proper reimbursement for the healthcare services that are rendered to the patients. The medical practice sustains if the revenue cycle is effectively and efficiently managed. People may think that a single visit to a doctor is simple, but in reality, there is vast amount of paperwork that is required in scheduling and more so if a medical procedure or further treatment is required.
How Medical Billing is connected to Revenue Cycle:
The paperwork is key in the revenue cycle as the medical practice will only be reimbursed from the insurance providers if the medical bills are properly processed. The medical information should be meticulously processed and tracked to ensure that healthcare providers such as doctors, nurses, physicians, lab technicians, therapists, and social workers are rightfully compensated for their services.
The medical information that is documented includes
- The type of disease
- The medical procedure that was conducted
- The medical supplies or equipment that was used
Medical Billing and Coding are the two most important elements in a healthcare system that ensures that information and data are properly tracked, and there is a regular flow of information between the healthcare providers and insurance companies.
Medical billing and coding are done by qualified and experienced medical professionals who are skilled at reading, interpreting, recording, and tracking complex medical information efficiently. Medical billing is the process where the healthcare provider properly documents, submits, and do follow-ups on medical claims with the healthcare insurance companies to receive payment for the services given to the patients.
Medical coding, on the other hand, is the process where a coder takes the information according to diagnosis, procedures, treatments, equipment, and medicines used and translates it into alphanumeric codes. Medical coding is an essential task as the entire reimbursement that streamlines the revenue cycle depends on correct medical coding based according to the diagnosis and treatment given to patients.
Medical billing and coding is a complicated and challenging task and requires meticulous and careful documentation. Both big and small medical practices see a constant stream of patients and more so in times of ongoing Coronavirus pandemic. The medical practices must integrate hospital billing system software to not only increase the workflow but ensure that claims are correctly processed and submitted, and payments are collected on time instead of rejected claims.
The 10 Key steps for Successful Medical Billing
1. Patient Check-In or Registration
The first and foremost step is to note down the patient’s details, such as his/her age, gender, address, and phone number. The insurance-related information is key and also taken down which includes
- Insurance plan
- Policy ID or number
- Name of insurance payer
The demographic information and insurance details must be carefully noted and should be updated if the patient regularly visits the medical practice as it forms the basis of a medical claim for which the healthcare providers will be compensated. Today most practices use advanced medical billing and coding software where patient details are entered only once, and patients do not have to go through the trouble of giving information every time they visit the hospital or clinic.
2. Insurance Verification
Patients need to verify their insurance information and eligibility in every appointment and visit the medical practice as an insurance plan, and coverage status can change anytime. The healthcare provider should ask and double-check as it can have directly on the claim processing and resulting reimbursement.
The status of insurance is also asked, and only active insurance plans would be processed, and if the mentioned medical services are covered or not; otherwise, the patient has to make a payment on his own. Any changes in the insurance plan or policy impact the patient’s authorization information and benefit.
3. Patient-Provider Meeting
The term ‘Encounter’ is used to denote the meeting with the healthcare provider. The patient mostly explains the symptoms or medical problems, and the provider evaluates the information and takes the decision on the appropriate treatment. The meeting is audio or video recorded to ensure that the right details and diagnosis were done and claims could be prepared accurately.
4. Medical Transcription
A qualified and experienced professional will listen and see the recording to correctly document the patient information in a medical script, which is later used to maintain and update if the patient comes again for a visit. This step should be error-free as the information is used for correct treatment and follow-ups. Any mistake can affect patient medical history and result in incorrect decision making. The medical script is also used for billing purposes, and an error can result in claim rejection.
5. Medical Coding
The American Medical Association has specified certain guidelines that a professional coder uses to convert the medical information into alphanumeric codes. The information includes
- The reason for the visit
- The type of diseases diagnosed
- The treatment is done by a health provider to cure the disease
- Where the medical service was provided
The coders use CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes to correctly assign the procedure or service so insurance payers can easily assess the amount of payment to be made.
6. Charge Entry
The expenses incurred to render the service is added to the amount that is calculated by the medical coder. This is the first step in preparing the claim form that is submitted to the insurance company, and without a definite and accurate amount, the payment cannot be collected. The claim form is thoroughly checked to ensure the right amount is quoted as it resulted in either reduced payment or claim rejection altogether. The medical claim forms mostly provide
- Patient Information
- Patient’s medical history
- Procedures provided with correct codes
- National Provider Index (NPI) number and insurance provider
- Place of service code
7. Claims Submission
The claim is ready once the patient information, health provider information, and service provided are added to the claim form and will be submitted to the insurance company for reimbursement. Today with the help of technology, the claims are submitted electronically through a system called ‘Electronic Data Transfer (EDI).’ There are three stages that ensure proper claim submission
- Electronic Health Record (EHR) software checks if the relevant fields in the claim form are filled or not and the corresponding coding.
- The given patient information is verified by third-party EDI vendors such as name, Date of Birth (DOB), name of the policy, and possible coding errors
- The insurance company also verifies the patient information, sees if the policy and action, and check for coding errors. If there are any discrepancies, then the claims are returned to the health providers as rejected.
8. Claim Denial Management
The insurance company only processes the claims that are received within a specified time limit. Once the claim is accepted, then also certain checks are made, and sometimes the claim is paid in full, and sometimes a part of the claim is paid, and the rest of the charges are denied. The medical practice has a team that reviews the claim and resends it to recover the denied charges and ensure full revenue is generated. A list of trends or rejection issues is noted to prevent future claim rejection.
9. Accounts Receivables
The claims denied even after corrections are followed rigorously with the insurance company, and further information is gathered that caused a denial of payment. The Insurance Coding, Medical Coding, and Charge Posting are shared to see for any errors.
10. Payment Collection
Once all the checks are done, and the insurance company decides to pay the claim, then either a paper check or electronic fund transfer is made. Bulk payments are sent along with a summary called Explanation of Benefits (EOB). The professional team at a medical practice is responsible for posting entries in the EHR software to match the payment received.
Reasons to Implement Medical Billing and Coding Software:
Many of the insurance companies follow their own set of guidelines, so it is better for the medical practice to check with each insurance payer and accurately follow the policies to ensure proper claims submission and payment collection.
The use of advanced billing and medical coding software allows to automate the entire billing process and remove the risk of any errors that can result in claim rejection, which will disrupt the entire flow of regular revenue stream. In times of global pandemic, the medical practices are already overburdened and need all the right resources, such as billing software that can be integrated with the hospital’s existing management system.
With proper medical billing software programs, medical practice does not have to spend time and effort in recruiting the ideal candidate who can manage the billing and coding tasks. Also, with the software, the mistakes, typographical errors, and coding errors can be removed and streamline the entire revenue cycle process.
PETTIGREW is one company offering advanced and customizable medical billing, and coding solutions for hospitals, health centers, and numerous physician clinics. PETTIGREW believes that future of managing medical administrative tasks is through cost effective and innovative software that offers unique value added digital services.
Our team is technically qualified and skilled and knows how to develop software and solutions according to requirement of particular medical practice and then connecting it with specific insurance company. PETTIGREW billing software is compliant with industry standards and optimizes the claim processing, improves accuracy and reduces any risk and financial loss.