The billing process is an interaction between the provider and the insurance company (payer). It begins with the office visit. After the provider sees the patient, depending on the service provided and the examination, the doctor creates or updates the patient's medical record. This record contains a summary of treatment and demographic information related to the patient. Upon the first visit, the provider will usually give the patient a diagnosis (or possibly several diagnoses), in order to better coordinate and streamline his/her care. The patient record contains personal information, nature of illness, prognosis and suggested treatment as well. This whole process - the first visit - is called an ‘encounter’.
The treatment, diagnosis, and duration of service combine to determine the procedure code that will be used to bill the insurance. The doctor then either provides this information to a medical coder or other billing specialist. From this, a billing record, either paper (usually on a standardized form called an HCFA, named for the previous name for the Centers for Medicare and Medicaid Services) or electronic, is generated. This form includes the various diagnoses identified by numbers from the current ICD-10 manual.
This billing record or claim is then submitted either to a clearinghouse that acts as an intermediary for the information (this is typical for electronic billing) or directly to the insurance company. Some of the electronic transactions are sent via Electronic Data Interchange (EDI).
Choosing a clearinghouse is very cost effective for medical billing because they edit the claim based on the rules stated by the payer. If the claim does not meet necessary criteria, the claim is sent back to the user, so they can make corrections and quickly retransmit it. This saves time as well as later complications.
The insurance company (payer) processes the claim. The insurance side of the process begins with testing the validity of the claim for payment. The tests cover patient eligibility for payment, provider credentials, and medical necessity. Upon passing successfully the tests, the payer pays the claim. If a claim fails the tests, the payer rejects the claim and communicates the rejection message to the claim submission source.
Upon receiving the rejection message, the provider must decipher the message, reconcile it with the original claim, make required corrections, and resubmit the claim again. This exchange of claims and messages may repeat multiple times until the claim is paid in full.
The frequency of rejections, denials, and underpayments is high (often reaching 50%), mainly because of high complexity of claims and data entry errors. Straight Through Billing technology, procedures, and training help manage the billing process to receive all
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