Preceding the revenue generated by healthcare organizations, there is a whole series of complex steps involved, collectively known as medical claims processing. Healthcare Providers’ reimbursements depend purely on the accuracy of medical claims billing. Therefore, it is essential that the billing staff pose utmost care while carrying out medical billing operations. But, how is medical claims processed in healthcare? To understand, lets break down this huge process into to front-end and back-end operations. Although, most medical claims processing happens at the back-office, errors in claims can arise right after a patient is registered at the front office. Scroll down to learn more about the process:
Front-end Operations:
- Patient Registration: The first and the foremost step in medical claims processing is to register patients as and when they arrive at a hospital. The front-office staff will either create a new patient account or update the existing ones. Patient demographics are captured and it should be done accurately. A HIPAA form is signed by patients at this stage.
- Verification: The next important step is to do a detailed insurance verification. The staff must check patients’ medical coverage and let them know whether they are eligible for in-network services. Also, at this stage, the staff must let patients know about their financial responsibility. It will ensure uninterrupted cash flow at the end.
- Check-out: All patient services are logged in their respective medical records once they are rendered. After receiving the services, patients are expected to pay their balances during checkout.
Back-end Operations:
- Medical Billing and Coding: Right from medical procedures and diagnoses to prescriptions, everything is translated in to specific CPT codes. Since the implementation of ICD-10 Coding Nomenclature, new codes are being used. Intense training should be offered to the medical claims billing staff, so they perform error-free medical billing and coding.
- Charge Entry: Once CPT codes are created in the medical claims billing operation, the PMS (Practice Management Software) will automatically generate a charge for each CPT code. The billing staff must check for accuracy once all charges are entered.
- Claims Submission: The next step is to submit the generated claims to the Payers. Each Payer has different submission requirements. Therefore, the medical claims processing team must show extra care to avoid denials. To ensure timely reimbursements, all claims should be submitted in a timely fashion. Gone are the times when paper claims were submitted! In the present era, claims are transmitted electronically, which is faster and environmentally-friendly.
- Clearinghouse: It is third-party company between a medical practice and an insurance company to which all claims are transferred to. The main purpose of clearinghouses is to format the claims as per Payers’ requirements before submission.
- Reimbursements: After receiving claims from clearinghouses, Payers review them using a process called adjudication. The bills are evaluated and paid accordingly. If there are errors in the bills, then they are sent back to the medical practices.
The whole process starts over again if there is a claim denial. The claims are analyzed for errors, corrected and re-filed. With so many responsibilities, many US medical billing companies find it hard to perform medical claims processing in-house. Therefore, outsourcing would be a better option for good revenue generation.
About MGSI:
If you are looking for an experienced and reputed medical billing company in the US, then consider MGSI, based in Florida. This medical billing company has more than 20 years of experience in performing exceptional medical claims processing. MGSI is an A+ rated company with Better Business Bureau. It is HIPAA compliant, ensuring high levels of security to patient information. To learn more details, log on to www.mgsionline.com.