A Comprehensive Guide to the Medical Billing Process in Healthcare Organizations

Recognizing the Billing Process

A wide range of medical services are billed to third parties by healthcare providers, particularly local health departments (LHDs). The sharing of data is at the core of the provider-patient interaction. This comprises not just procedural or bureaucratic details but also counseling and resources supplied to the patient as part of the medical appointment by the physician or LHD.

As a result, several types of data are fed into the medical billing process at various times. The medical billing process starts when a patient enters an LHD by appointment or as a walk-in patient. Collecting insurance data from the patient is the initial encounter and an example of information sharing. This could be private insurance, government insurance like Medicare or Medicaid, or additional insurance. Even if the person has previously visited the LHD, obtaining insurance details should be repeated to record any changes. Validation and qualification by the insurance company are key pieces of information gathered.

Additionally, the LHD or provider will collect co-pays, deductibles, or self-pay sums. The data obtained at this stage is crucial for avoiding billing inaccuracies and mistakes. Insurance claim denials, potential income loss, and the investment of extra staff resources to hunt down payments, edit, and resubmit claims result from failing to capture and verify this data. Following the front office engagement, the person will frequently meet or communicate with a healthcare expert. This person could be a registered nurse, nurse practitioner, physicians assistant, or doctor.

Additionally, the LHD or provider will collect co-pays, deductibles, or self-pay sums. The data obtained at this stage is crucial for avoiding billing inaccuracies and mistakes. Insurance claim denials, potential income loss, and the investment of extra staff resources to hunt down payments, edit, and resubmit claims result from failing to capture and verify this data. Following the front office engagement, the person will frequently meet or communicate with a healthcare expert. This person could be a registered nurse, nurse practitioner, physicians assistant, or doctor.

Usual Medical Billing Errors:

Important medical billing errors can occur at many points during the patient-provider relationship. LHDs must be aware of possible major billing issues and how to successfully prevent them from preventing them from managing a cost-effective and efficient medical practice. This section discusses some of the most common medical billing issues and blunders.

Insurance Verification Failure:

Insurance concerns are the leading cause of insurance claim rejections. Failure to verify is frequently caused by dependence on a routine. Consider a patient who comes in regularly. In this situation, the staff thinks that the insurance provider or coverage plan has stayed the same and fails to confirm qualification appropriately on each occasion. Because insurance data might change at any time, confirmation is an important first stage in the billing cycle for every patient visit. To avoid the following insurance-related medical billing issues, LHDs must verify eligibility before providing services to patients:

• On the date of service, coverage had been discontinued or was otherwise ineligible: A change in insurance status, which either cancels a plan or integrates a switch between private insurance and Medicaid, is one of the more common occurrences. This is especially true in volatile economic times, when people may face several losses or long-term unemployment. As a result, LHD front office employees must assess each patients qualification at each visit to confirm that the patient is insured on the treatment date and is qualified for more than one program or health plan. A related issue is whether or not an LHD is deemed a contributing provider under the health plan. If LHD personnel fail to check qualification or provider status, claims may be denied after the fact, placing the responsibility on the LHD to chase down self-pay, which patients may or may not be able to give.
• Services not authorized: In other circumstances, a person may actively participate in a health care plan, but the plan may not authorize certain treatment care from the LHD that the person wants or needs. Even though this is a problem with public insurance, LHDs still worry about getting the cost of treatment back. If you make this medical billing mistake, the payer wont pay the claim because they didnt agree to the treatment. Once the service is given to the patient, the LHD is under pressure to pay back the costs. Obtaining permission before giving service eliminates this problem.

• Services not covered by the plan: Front office workers who fail to check which services a health plan covers, similar to permission difficulties, can expose the LHD to insurance claim denial and corresponding investment risk. To deliver non-covered services, the LHD shall explain the treatment that is not covered, if covered options are available, the cost of the service, and terms of payment or plans to the patient.

• Maximum benefits reached: In some situations, a person may have attained the full benefit in his or her plan for a specific period of time or event. If an LHD fails to identify these boundaries, the subsequent claim will be denied by insurance.

The Incomplete Claim:

Multiple electronic forms or physical documents must be created and submitted during billing. Many medical billing systems now permit insurance paperwork to be saved in a database or electronic format, thanks to the introduction of electronic health records (EHR). Medical professionals gather information at several points in the record-building process, including the previously described demographic and insurance data and the providers engagement. Healthcare providers rely on a "superbill" that tracks customer services to calculate the amount to be included on a specific claim. The superbill, also known as an encounter form, contains information about the services delivered and a statement of why the services were delivered.

Coding Errors:

An authentic portrayal of the services supplied to the client is required to file an insurance claim. The claim describes the services given by utilizing several diagnostic and procedural codes. Sometimes errors during coding amount to medical billing errors.

Lacking Specificity:

Third-party payers frequently decline claims for not being classified in the utmost detail or for being shortened to diagnostic codes. Qualified medical billing coders know that each diagnosis must be coded to the top level for that code, which is the codes maximum number of digits. If the LHD staff members in charge of filing insurance claims are unfamiliar with coding, the LHD stands a higher risk of claim denial.

Missing Filing Deadlines:

The timeframes for submitting can vary greatly based on the rules implemented by various third-party payers. Some insurers allow two years to file some medical claims, while others only allow thirty days. Due to this difference and the need for proper information, people often miss the deadline and cannot file a claim within the specified period.

Overcoming Medical Billing Mistakes:

The best way for a doctor or LHD to fix medical billing mistakes is to look for ways to reduce mistakes. Based on what we know about the industry, the following ideas are good ways for an LHD to fix important and common medical billing mistakes. The recommendations are not necessarily exclusive and may not apply to all LHDs. In many circumstances, elements unique to a single LHD may define how that LHD handles medical billing error solutions.

Invest in Staff Training:

The level of job training in medical billing difficulties significantly affects the number and intensity of medical billing mistakes, regardless of whether an LHD has a dedicated billing team or personnel with numerous job duties. Given the volatile regulatory and economic environments, LHDs must invest in well-trained personnel to develop (or sustain) income streams related to third-party billing payers. This investment can take numerous forms, including direct medical billing and coding regulations.

Improved Procedures and Protocols:

Many medical billing problems occur as a result of billing procedure malfunctions. More stringent regulations or recorded procedures can reduce the likelihood of claim denials in these circumstances.

Billing can be outsourced in part or in full:

In many circumstances, by outsourcing the task to a certified third-party contractor, LHDs can minimize or remove medical billing problems. In these circumstances, the LHD will free up staff resources to focus on other administrative or medical matters. These medical billing organizations get service data from clinicians to fulfill the cash flow back-end operations.

Audit Claims:

Finally, LHDs should incorporate an internal audit procedure for submitted claims. Auditing denied claims to determine what mistakes or omissions were committed to filing the claim is part of this process. Suppose the LHD discovers a relatively large number of requests being denied owing to insurance coverage difficulties. In that case, procedures can be implemented to address front-office workers who may need to make more mistakes during the intake and insurance confirmation stages. However, if several claims are being denied owing to treatment and diagnosis miscoding, an LHD can focus on improving communication between care providers and billing personnel.

Conclusion:

A consistent and reliable funding source is required to run a profitable, efficient LHD. This includes increased invoicing engagement with third-party public and private payers for LHDs. On the other hand, an increase in healthcare billing claims can result in an increase in medical billing errors and mistakes. This white paper discussed seven of the most common medical billing errors and provided ideas on how physicians and LHDs might collaborate to reduce their failure rates.