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What is The Claim Preparation Process in Medical Billing?

By Alyssa Martinez @ItsMariaAlyssa

If you're a healthcare provider, you know that you have to start on the claim preparation and billing process after treating a patient. If you're unfamiliar with the process, then the task will undoubtedly be daunting.

But you can always seek the help of a medical billing company.

For instance, if you're a physical therapist, you can hire a third-party physical therapy billing company with the experience and tools to quickly and accurately complete the billing process. Besides, the outsourced biller will peel away all the worries and anxieties that come with medical billing.

But before you hire a professional for the job, let's familiarize you with how the claim preparation process works.

1. Patient Registration

When a patient books an appointment via phone or physically checks into your practice for the first time, they should register by providing their personal details. Some practices give patients a form to fill with their demographic and insurance details.

Some of the data captured on the form may include:

· Patient names
· Physical address or phone number
· Date of birth
· Social Security Number
· Name of the insurance company
· Name of the policyholder
· Policy number

The personal details will help the practice determine if the patient is eligible to receive services offered depending on the insurance coverage. The patient's identity should also be verified once they give their details to ensure they aren't using another person's coverage. This can be done by checking their government-issued ID or any other form of identification.

If your practice fails to verify the patient's identity, you will be liable for fraud if the patient uses someone else's coverage as their own.

2. Confirm Insurance Eligibility

Insurance coverage is often different between providers, plans, and individuals. Thus, the biller needs to verify the patient's eligibility for the services offered.

In case the insurance doesn't cover the services to be rendered or part of them, the biller should let the patient know.

Part of this step also involves checking if the patient's insurance cover has elapsed or if there are prior insurance authorization requirements to be met before offering the treatment.

3. Coding Of Medical Diagnosis and Procedures

After the completion of the initial paperwork, the patient will go and see the physician. The physician's medical report also referred to as the superbill, is sent to the medical coder. The information from the report ought to be correctly coded.

Accurate coding is fundamental as it enables the insurance payer to assess the claim accurately. Medical coders should be careful to avoid over or under coding mistakes. The coder must also follow the Current Procedural Terminology and International Statistical Classification of Diseases codes.

Clinical documentation justifying the coded claim must be available. Including such attachments to the coded claim increases the odds for the claim to be successful. Some medical procedures also require additional documentation, which can shorten the claim process if the documentation is included in the initial submission.

Claims often have a similar format, and some of the information provided includes:

· Patient information
· Procedures performed
· Price of the procedures performed
· Provider information as per the National Provider Index number
· Place of service code or the type of facility

4. Claim Submission

Once the claim is prepared, it should be submitted to the insurance provider for payment. If your health facility is covered by the Health Insurance Portability and Accountability Act (HIPAA), you should submit the claim electronically.

Electronic claims have fewer errors, are more efficient, and take less time to get to the payer. Billing electronically also saves your practice money and time.

The provider also needs to check if they need to prepare a claim using a payer-specific billing guideline.

5. Claim Adjudication

Once the payer receives the claim, they evaluate it and decide if the claim is valid and how much they will reimburse the provider.

At this stage, a claim will be accepted if it's found to be valid. It may also be rejected if it's found to have some errors. If the claim is rejected, it's sent back to the biller who corrects the errors and resubmits it. A claim can also be denied where the payer decides not to process the payment for the services offered.

When the claim is accepted, the payer also sends the biller a report detailing the claim amount they will pay. If some medical procedures won't be covered, the payer provides reasons why.

In case the biller doesn't agree with the payer's report, they may opt to pursue a claim appeal where they attempt to secure the right reimbursement for services rendered.

6. Payment Statement Preparation

This last step involves preparing a statement for the patient detailing the amount paid by the insurance provider. The statement also provides the bill's portion that the patient has to pay out of their pocket, if any. Medical bill statements should be accurate and timely.

The biller must follow up with the patient to ensure their part of the medical bill is paid. Once the patient pays, this is recorded in their medical file.

In conclusion, the claim preparation and billing process can be daunting if you don't have the time or knowledge to complete it. A medical billing company can help you with the claim preparation process leaving you enough time to focus on your patients.


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