1. MEDICAL BILLING PROCESS

8. DEMO ENTRY DEMOGRAPHICS OF THE NEW PATIENTS ARE ENTERED INTO THE BILLING SOFTWARE AND UPDATION OF THE OLD ACCOUNS ARE DONE.

10. CLAIM GENERATION OR CHARGE ENTRY ONCE THE ACCOUNT OF THE PATIENT IS CREATED IN THE BILLING SOFTWARE, CHARGE CAN BE POSTED.

13. CLAIM ADJUDICATION Processing of paper claims starts in the mailroom where the envelops are opened, attachments unstapled, and clipped to the claim. Claims are then scanned into the computer. Processing of electronic claims begins when a file of transmitted claims is received from the clearinghouse. ( The clearinghouse edits the claims before sending to the insurance companies) and is opened in the claims processing computer.

15. CLAIM ADJUDICATION – Cont. Any service determined to be a non-covered benefit is marked as an uncovered procedure or non-covered procedure and rejected for payment. Services provided to a patient without proper authorization or that are not covered by a current authorization are marked as an unauthorized service. Patients may be billed for uncovered for non-covered procedures, but not for unauthorized services. 3. Procedure codes are cross-matched with the diagnosis codes to ensure the medical necessity of all services provided. Any service that is considered not “medically necessary” for the submitted diagnosis code may be rejected. 4. The claim is checked against common data file. The information presented on each claim is checked against the insurer’s common data file, which is an abstract of all recent claims filed on each patient. This step determines whether the patient is receiving concurrent care for the same condition by more than one provider. This function further identifies services that are related to recent surgeries, hospitalizations, or liability coverage's.

16. CLAIM ADJUDICATION – Cont. 5. A determination is made by “allowed charges”. If no irregularity or inconsistency is found on the claim, the allowed charge for each covered procedure is determined. (The allowed charges is the maximum amount the insurance company will pay for each procedure or service, according to the patient’s policy. The exact amount allowed varies according the the contract and is less than than or equal to the fee charged by the provider, Payment is never greater than the fee submitted by the provider). 6. Determination of patient’s annual deductible obligation is made. ( The deductible is the total amount of covered out-of-pocket medical expenses a policyholder must incur each year before to insurance company is obligated to pay any benefits) 7. The co-payment or co-insurance requirement is determined.

17. CLAIM ADJUDICATION – Cont. 8. The Explanation of Benefits (EOB) is completed. The (EOB) form or report is a statement telling the patient or provider how the insurance company determined its share of the reimbursement. The report includes the following: a). A list of all procedures and charges submitted on the claim form. b). A list of any procedure submitted but not considered a benefit of the policy. c). A list of all the allowed charges for each covered procedures. d). The amount of the patient deductible, if any, subtracted from the total allowed charges. e). The patient’s financial responsibility for cost sharing (co-payment for this claim. f).The total amount payable by the insurance company on this claim.

18. CLAIM ADJUDICATION – Cont. 9. EOB and benefit check is mailed. If the claim form stated that direct payment should be made to the physician, the reimbursement check and a copy of the EOB will be mailed to the physician. This can be accomplished in one of three ways: a). The patient signs the Authorization of Benefits Statement, Block 13 on the CMS – 1500 form. b). The Physician marks “YES” in Block 27 on the CMS – 1500 form. c). The Physician has signed an agreement with the insurer for direct payment of all claims. If reimbursement is to be sent to the patient, the policyholder will received a copy of the EOB; explanation is sent to the provider by most carriers, without payment.

19. PAYMENTS PAYMENTS: Amount paid to the physicians against the services rendered by them to the patient. THE SERVICES THAT ARE PROVIDED TO THE PATIENTS ARE SENT OUT TO THE INSURANCE COMPANIES IN THE FORM OF CLAIMS. THESE CLAIMS GET PAID BY THE INSURANCE COMPANIES. THE PAYMENTS ARE RECEIVED AT THE PROVIDER’S MAILING ADDRESSES AND / OR AT THE BILLING COMPANIES’ ADDRESSES. IN CASES WHEN THEY ARE RECEIVED AT THE PROFIDERS’ ADDRESSES THEN THEY ARE IN TURN FORWARDED TO THE BILLING COMPANY TO THE PAYMENT IN THEIR SYSTEM. SUCH PAYMENTS COME IN THE THE FORM OF BATCHES AND MAY HAVE BANK’S DEPOSIT SLIP OR PAYMENT LISTING WITH THEM. PAYMENTS THAT ARE RECEIVED DIRECTLY AT THE BILLING COMPANIES’ ADDRESS DO NOT HAVE THE BANK’S DEPOSIT SLIP. SOMETIMES, IN THE CASE OF NON-PARTICIPATING PROVIDER’S, PAYMENTS ARE RECEIVED BY THE INSURED PARTIES ADDRESS AND THEY FORWARD THE PAYMENT TO THE PHYSICIAN’S ADDRESS.

20. DENIALS Claim that do not get paid, come back as Denials from the Insurance carriers. This can be due to posting errors, incorrect procedure / diagnosis codes, lack of information (medical records) while filing the claims, or missing / incomplete patient details. Denials are broken down into two categories: In-House and Patient Responsibility. In-House denials are the ones that require some type of correction from our part and can be resubmitted. We do not bill patient. Patient Responsibilities are those denials that we can’t do anything to get the claim paid by the insurance company. Al we can do is, transfer the charge to the patient with the correct message code.

23. MEDICAL BILLING FLOW CHART

24. THE END