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Medical Billing Workflow

Medical Billing Workflow

     Note : In Medical Billing, people use different words for the same thing; Here are those most commonly used;

1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information;
3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code; ( ICD means International Statistical Classifications of Diseases. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.Some example for ICD Codes)
   
5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; (CPT means Current Procedural Terminology codes, are procedural codes published by the American Medical Association, describing what services the provider actually performed on the patient. Some example for CPT Codes)
6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
9. Once the Claim is prepared and send to the Insurance company for payment; 
10. Insurance company pays the doctor office;

     Use case 2 : In House Billing with Two Insurance

Many patients only have one insurance plan but it is  possible for a patient to have two or three medical insurance policies. The first insurance billed would be
the primary insurance. The next one billed would be the secondary, and the last would be the tertiary.

First the primary carrier must be billed first and then balance is billed to the second insurance carrier with the primary insurance payment  information.
If there is a third or tertiary insurance, it is billed last with payment information from the first two.


1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information; 
3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
8. Once the Claim is prepared and send to the Primary Insurance company for payment;  
9. Primary Insurance company pays the doctor office; 
10. Billing Department notified that claim has still some balance after Primary Insurance is paid. Since the Patient has another insurance (secondary), so now the billing department send the claim to the patient secondary insurance to collect the remaining balance.
11. Secondary Insurance Process the claim and pay the remaining amount to doctor office

     Use case 3 : Self Pay

Patients who are not covered by health insurance(does not have any insurance) are considered “self pay” patients. They or the responsible party they designate are totally responsible for their own bill. Not everyone is covered by health insurance. The ones that aren’t covered are considered self pay and just like in the old days, these people must pay for their visits themselves.

1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc). 
3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
8. Once the Claim is prepared and since there is no insurance for the patient, so patient statement is generated and send to the patient for payment;  
9. Patient Receives the Statement and Payment is made to the doctor office.

1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc). 
3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
8. Once the Claim is prepared and send to the Primary Insurance company for payment;  
9. Primary Insurance company pays only 80 % of the Bill to the doctor office; 
10. Since there is no other insurance for the patient and claim balance is still 20 %, so now the billing department change the responsibility of the balance to patient and patient statement is generated.
11. Billing Department send the Statement to the Patient.
12. Patient Receives the Statement and Payment is made to the doctor office.

     Use case 5 : Clearing House Work flow

1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
   
2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information;
   
3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);

4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code;

5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;

6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;

7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
   
8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
   
9. Once the Claim is prepared and send to the Insurance company for payment; 
   
   
10. Billing Department using the Practice Management System (PMS), send the claim via EDI File. The EDI Transaction used to create the claim in the Electronic format is EDI 837
    Refer the Following Link to understand more on EDI 837
    What is an EDI ?
    EDI 837 Health Care Claim
    
11. Once the 837 EDI File is created, then it will be send to the Clearing House.
    
12. Clearing House will validate the EDI File and send to the particular insurance company.
    
13. Insurance Company Process the Claim and prepare the Check (Cheque) and Statement(This statement is called Explanation of Benefits OR Remittance Advisory (EOB)          
    Refer the following Link for EOB
    EOB - An explanation of benefits 
    
14. Insurance company also generates the EDI 835 File using their System. EDI 835 is electronic version of EOB.
    The Electronic Remittance Advice (ERA), or 835, is the electronic transaction which provides claim payment information in the HIPAA mandated ACSX12 005010X221A1   Format. These files are used by practices, facilities, and billing companies to Auto Posting payments into their systems.
    Refer the following link for Sample
    EDI 835 Health Care Claim Payment/Advice:
    
15. Once the Check, Statement (EOB) and ERA File are ready, then insurance company first send the ERA File and EOB to the clearing house.Second , insurance company  will send the Check and copy of the EOB to the billing provider address . Third for each patient in the statement, the copy of the EOB will be emailed.
    
16. Now the Billing Team download the EOB and ERA from the clearing house. If the PMS system has Auto Posting Using ERA File, then they will download the EDI File and do auto posting. If there is no auto posting Module, then they will download the EOB PDF and apply posting manually.Remember, some time, ERA/EOB file will be reach the clearing house, even before the insurance company send the payment check to the doctor.

Available link for download

Posted by Unknown at 2:22 AM

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Labels: billing, medical, workflow