Owning and operating a medical practice is not for the faint of heart. There is so much to do every day with just the clerical work, let alone the emotional and physical labor that comes with treating patients to keep them healthy. It’s a heavy burden to place on anybody’s shoulders.

A practice cannot be merely a place where a patient gets incredible treatment. It’s a place where that information must be closely guarded for privacy’s sake, and you also have to keep in-depth records of each person that is seen and treated. On top of that, you must also make sure that the billing process is accurate, efficient, and done in a way that is — as best you can — easily understandable.

That’s why medical billing is so important. Going to a doctor is a simple thing in theory, but it’s actually quite complex. There is a system that co-exists around each visit by a person to their doctor; there is a patient, the provider of the care (whether a private practice, hospital, emergency room or health clinic), and the insurance company that the patient is registered with.

How Medical Payment Systems Work

As a medical biller, the job is arrangement of the payment system between the three different parties. That allows the patient to get top-quality care, the provider to be compensated for the quality of care they provide, and the company to make sure that both the provider is compensated and that revenue is generated by the patient. That’s why each patient is required to fill out a series of forms with information, because some of this information is for the provider but other parts of it as for the medical biller. The biller then takes the information provided to generate a bill for the insurance company — a claim — which then gets reimbursed by the insurer, who then goes to the patient and gets any revenue generated (should the patient’s plan call for a co-pay).

The medical billing process is one of the foundations of health insurance, which can take on various forms;

• Pay-for-service insurance: which can be more expensive but more flexible in how a patient picks their provider.
• Managed care organizations: which includes HMOs and PPOs with lower premiums and deductibles but less flexibility when it comes to provider choice. This is much more common in the United States.

Claim Creation

Claim creation is when the billing system overlaps with coding, another integral part of a healthcare provider. Whether it’s a procedural code of a common code, either of those systems tell a payer what the services rendered were by a provider. Then there is a diagnosis code, which describes why a patient was in to see a doctor and what their physical issue was or is.

After adding the personal information gathered, that’s how the claim is generated. It also includes a cost of the services performed, giving the claim a fuller picture of the visit that just occurred. The biller makes sure the claim is compliant first, checking and double-checking every fact on the claim form, before submitting it to a healthcare provider for reimbursement; that claim may also, depending on the patient’s level of insurance, be sent along to the patient for their co-pay balance.

What Else Do Outsourced Medical Billing Companies Do?

If the job was just about processing bills and submitting claims, it would be so much easier than what the job as a medical biller really is. Yet, it’s so much more.

The biller is one of the key point people in contact with a patient, between making sure that they have the correct information needed to complete a claim, then making sure the claim is submitted correctly and following up on payment processing. A biller also works with patient medical records, using the codes that are put on the records as part of the billing process. There is also the technological aspect of things and making sure that the management software a practice uses has all the information that is generated to allow for patient tracking, scheduling and medical record storage in an efficient manner.

The biller, while compiling a claim, must also know what types of claims each insurance company accepts, because sometimes they are not one-size-fits-all. Billers will work with clearinghouses to make sure the process is as streamlined as possible, has no errors, and can be processed efficiently to make sure the claim is closed in short order. To do that, a biller is consistently talking with payers, providers and patients. And in a worse-case scenario, a biller may have to arrange for debt collection on delinquent bills.

At Med USA, we have decades of experience in medical billing so you can focus on what’s important: Giving the best possible medical care to your patients. Talk to a Med USA billing expert and let’s discuss how we can work together.

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