The medical billing process involves several key steps including patient registration, confirming financial responsibility, check-in and check-out, claims creation, compliance checking, and following up on payments. Claims are prepared using a superbill, and once submitted, they undergo adjudication by the payer, which can result in claims being accepted, rejected, or denied. Billers must generate patient statements that reflect the owed amounts and may involve collections if payments are not received promptly.

1. THE MEDICAL BILLING PROCESS

2. THE MEDICAL BILLING PROCESS
● Consists of
○ Registration
○ Establishment of financial responsibility
○ Patient check-in and check-out
○ Creation of claims, checking compliance, and
transmission of claims
○ Monitoring adjudication
○ Generating patient statements
○ Following up on patient payments/Collections

3. PATIENT REGISTRATION
● When a patient calls to set up an
appointment with a provider, they effectively
pre-register
○ They provide their name (so you can check if they
are an established or new patient)
○ They will typically provide the reason for the visit
(e.g. an illness or a general check-up)

4. CONFIRM FINANCIAL RESPONSIBILITY
● Financial responsibility describes who owes
what for a particular patient’s visit
● Once the biller has the patient’s insurance
information, they can determine who they
will have to bill, and for what services
● Certain insurance plans do not cover certain
certain procedures or services, so the biller
must pass the responsibility for those onto
the patient

5. PATIENT CHECK-IN
● Patient will be asked to
○ Provide identification
○ Complete forms (like HIPAA forms)
● The Biller will
○ Collect co-payments
● Co-payments are always collected at the point of service

6. PATIENT CHECK-OUT
● After the patient checks out, the physician
passes the medical report to the coder, who
will put the appropriate codes for the
procedure into a superbill
○ The superbill also contains important
demographic information, medical history,
provider information, etc.
● The superbill is then transferred to the biller,
who will use it to create a claim

7. PREPARE CLAIMS
● Billers take the superbill from the coder and
use the information to create the claim
● The claim will also include the cost of the
procedures performed
● Billers will adjust this cost when they send it
to the payer
○ That is, they won’t send the full cost to the payer,
but rather the amount they expect the payer to
pay, per the payer’s contract with the patient and
the provider

8. THE MAKEUP OF CLAIMS
● Claims may vary in format, but they all
contain the same information, more or less
○ Patient information
■ Like medical history or demographic info
○ Procedures performed
■ Listed using either CPT or HCPCS
○ Diagnosis
■ Listed using ICD-9-CM; demonstrates medical necessity for
procedure
○ Price of procedure(s)
○ Provider information
■ Listed using NPI codes
■ May also include a Place of Service code
● These describe what type of facility (e.g. ambulance or
reservation clinic) performed the service

9. CHECK COMPLIANCE
● Coding Compliance
○ This is generally left to the medical coder, but
billers should be able to spot and correct coding
errors, if necessary
● Billing Compliance
○ Bill must meet guidelines laid out by HIPAA (see
Course 3-8) and by the Office of the Inspector
General (OIG)

10. TRANSMIT CLAIMS
● HIPAA
○ Health Insurance Portability and Accountability
Act of 1996
○ Requires all entities covered by it to meet certain
standards
■ Standard transactions (like claims) submitted by these entities
must be done so electronically, except in certain cases
■ Does not require all transactions to be done electronically, just
a certain set of them
■ Most providers, clearinghouses, and payers are covered by
HIPAA

11. TRANSMIT CLAIMS
● In the case of high-volume payers, a biller
may submit the claim directly to the payer
○ Medicare and Medicaid are high-volume payers
● Otherwise, the biller may submit the claim
through a clearinghouse

12. CLEARINGHOUSES
● Third-party organizations that act as an
intermediary between billers and payers

13. CLEARINGHOUSES
● They take information for the claim from
the biller, and format them correctly for the
payer
○ Some payers require special formats or forms
○ Rather than sending ten different claims (each
with its own format) a biller can send the
information for ten claims to the clearinghouse,
which will format each accordingly and then send
them out
■ Saves billers time and administrative hassle
■ Clearinghouses “scrub” claims, ensuring they will be “clean”
● Clean claim: Formally and factually accurate; claim with
no errors

14. MONITOR ADJUDICATION
● Once a claim reaches a payer, it undergoes
adjudication
○ Adjudication = evaluation by the payer of what
services they will cover, and for how much
● A payer may accept, reject, or deny a claim

15. ACCEPTED CLAIMS
● Are deemed factually and formally correct,
and they adhere to the contract the payer has
with the patient and payer
● These are sent back to the biller with an
explanation of how much the payer will
reimburse
○ That total is taken out of the total cost of the
procedure
■ The balance is then sent to the patient

16. REJECTED CLAIMS
● Have some major or minor errors in them,
and are sent back to the biller to be corrected
○ Errors include a miscoded procedure or diagnosis
○ An incorrect NPI code
○ Missing information
● These are corrected by the medical biller and
then sent back to the payer

17. DENIED CLAIMS
● A claim the payer refuses to pay
○ One example: A claim for a procedure not
covered by the patient’s insurance policy, such as
■ A procedure related to a pre-existing condition
■ Coverage for certain prescription drugs
● These are sent back to the payer with an
explanation as to why they will not be
covered
● The total cost of the procedure is then passed
to the patient

18. APPEALING CLAIMS
● If the payer sends back a claim with a
reimbursement that is less than what’s
expected by the provider, or if the biller feels
that certain procedures should be covered
under the provider’s contract with the payer,
the claim may enter the appeals process
● Appeals is a lengthy negotiation with the
insurance company

19. APPEALING CLAIMS
● It is an administrative hassle, and will slow
things down for the biller and the provider
● It’s best to try and avoid the appeals process
whenever possible

20. GENERATE PATIENT STATEMENTS
● The Statement is the bill to the patient that
describes how much they owe for the
medical procedures
○ It includes the balance of the cost for the
procedure
■ Total cost – Payer reimbursement = balance (goes on patient
statement)

21. GENERATE PATIENT STATEMENTS
● Statements may include Explanation of
Benefits (EOBs), which inform the patient
why certain procedures, or certain amounts
of certain procedures, were or were not
covered by the payer

22. FOLLOW UP ON PATIENT
PAYMENT/COLLECTIONS
● Billers mail out bills in a timely fashion
○ Each provider has its own timeline of when a
claim is filed and when a patient statement is sent
out
● In case the patient does not pay their balance
with the provider on time, a collections
agency may be called in to ensure the
provider is properly reimbursed