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The medical billing cycle is a series of steps that lead to maximum, appropriate, and timely payment for patient’s medical services. The process consists of ten steps that take place before the encounter, during the encounter, and after the encounter. The first step is to preregister the patient; this takes place before the encounter when the patient calls to schedule an appointment. It involves two main tasks, to schedule and update appointments and collect preregistration demographics and insurance information (2014). New patients give basic personal and insurance information.
Every patient is asked about the medical reason for the visit. The second step is to establish financial responsibility. This step takes place during the encounter. Insured patients are asked a series of questions essential to knowing to correctly bill payers for patient’s services for that visit.
These questions also help medical insurance specialists ensure that patients will pay the bill when insurance does not cover some of the services. The patients are told that they are responsible for any charges not covered by the health plan.
Payment options are usually available if the bill will be substantial. The third step, which also happens during the encounter is to check in patients.
When there is a new patient that comes in they collect detailed, and complete demographic and medical information at the front desk. Returning patients are asked to make sure information is current and correct and check for any pending balances. Copayment is then collected. During the visit the physician evaluates, treats, and documents procedures preformed and treatment provided.
The fourth step is to review coding compliance. Every medical diagnoses and procedure must be assigned a medical code to bill for the visit. This is either done by the physician, medical coder, or insurance specialist. There are codes for specific procedures, such as surgery. Another group of codes cover supplies and other services. When assigning codes the employee has tofollow official guidelines.
Employee must always double check for errors. The fifth step is to review billing compliance. Each charge for a visit is related to a specific procedure code (2014). A separate fee is associated with each code, but every code is not billable. The payer’s rules determine if a code can be billed. Following the rules result in billing compliance. The sixth step is to check out the patient.
This is the last step that takes place during the encounter. Now that all coeds have been assigned and double checked and all balances and copayments have been taken care of a receipt is given for payments made. Last a follow up appointment is scheduled if ordered by the physician. The seventh step is to prepare and transmit claims; this takes place after the encounter. A major step in the billing cycle is the preparation of accurate, and timely health care claims. A claim gives information about the diagnosis, procedures, and charges to the payer. The claim could be for reimbursement for services or to report a visit to an HMO. Step eight is to monitor payer adjudication. Once claims have been sent out it is important to collect payment as soon as possible. The practice needs to receive this money known as account receivable to keep the business running.
The payer puts the claim through a series of steps designed to judge if it should be paid. The payer’s decision on the claim is then explained on a report and sent back to the provider with payment. If patient has more than one health plan the claim must be sent to them too. The ninth step is to generate patient statements. Most of the time the payers do not cover the full amount owed so the patients will be billed the remaining balance. Bills are mailed to patient with dates and services provided, any payments made, and the balance due.
The tenth and final step is to follow up payments and collections. The patient’s payment file is checked regularly for overdue bills. The collection process is started when payments are later then permitted. The patient’s medical and financial records are stored according to the practices policy. Federal and state regulations determine what documents are kept and for how long (2014). These ten steps should be followed to ensure correct and timely payment from the payer and the patient. The series of steps take place before, during, and after the encounter. Begins when the appointment is made and ends when payment is paid in full.
Valerius, J. D., Bayes, N. L., Newby, C., & Blochowiak, A.L. (2014). Medical Insurance [University of Phoenix Custom Edition eBook]. New York, New York: McGraw-Hill. Retrieved from University of Phoenix, HCR220 website.
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