The Evolution Of Drug Payment: Unraveling The Mystery Of Electronic Insurance Billing

The term electronic insurance billing refers to the process of submitting and processing healthcare claims for reimbursement, which is typically done electronically in the United States. This process involves healthcare providers creating detailed records of patient visits, including diagnoses, procedures performed, and prescribed medications. These records are then translated into standardised codes using a coding system such as ICD-10-CM or Current Procedural Terminology (CPT) codes. The coded records, along with patient demographic and insurance information, are submitted to health insurance companies or payers for review and payment processing. Most insurance companies follow a similar process, whether they are private or government-sponsored programmes.

The insurance company reviews the claim by verifying medical necessity and coverage eligibility based on the patient's insurance plan. If approved, the insurance company processes the payment directly to the healthcare provider or reimburses the patient. Healthcare providers may need to follow up on and appeal claims. Knowledge of medical coding guidelines and insurance policies is essential to ensure timely and accurate reimbursement for healthcare services rendered.

Medical coding

The process of medical coding starts with a patient encounter in a physician’s office, hospital, or other healthcare facility. When a patient encounter occurs, providers detail the visit or service in the patient’s medical record and explain why they delivered specific services, items, or procedures. Accurate and complete clinical documentation during the patient encounter is critical for medical billing and coding. The golden rule of healthcare billing and coding departments is, “Do not code it or bill for it if it’s not documented in the medical record”.

Providers use clinical documentation to justify reimbursements to payers when a conflict with a claim arises. If a provider does not sufficiently document a service in the medical record, the organisation could face a claim denial and potentially a write-off. Once a patient leaves the healthcare facility, a professional medical coder reviews and analyses clinical documentation to connect services with billing codes related to a diagnosis, procedure, charge, and professional and/or facility code.

There are a number of code sets that a medical coder must be familiar with, including the International Classification of Diseases (ICD) codes, which correspond to a patient’s injury or sickness, and Current Procedural Terminology (CPT) codes, which relate to what functions and services the healthcare provider performed on or for the patient. These codes act as the universal language between doctors, hospitals, insurance companies, insurance clearinghouses, government agencies, and other health-specific organisations.

The coder reads the healthcare provider’s report of the patient’s visit and then translates each bit of information into a code. There is a specific code for the type of visit, the symptoms the patient is showing, the tests the doctor performs, and the diagnosis. Every code set has its own set of guidelines and rules. For example, certain codes, like those that signify a pre-existing condition, need to be placed in a very particular order. Coding accurately and within the specific guidelines for each code will affect the status of a claim.

The medical coding process ends when the medical coder enters the appropriate codes into a form or software program. Once the report is coded, it is passed on to the medical biller.

Medical billing software

The medical billing process involves the systematic submission and processing of healthcare claims for reimbursement. Once services are provided, healthcare providers create a detailed record of the patient's visit, including diagnoses, procedures performed, and any medications prescribed. This information is translated into standardised codes using a coding system such as ICD-10-CM or Current Procedural Terminology (CPT) codes. These coded records are then submitted, along with the patient's demographic and insurance information, to the health insurance company or payer.

The insurance company reviews the claim, verifying medical necessity and coverage eligibility based on the patient's insurance plan. If the claim is approved, the insurance company processes the payment, either directly to the healthcare provider or as a reimbursement to the patient.

• Scheduling appointments
• Entering patient information automatically
• Scrubbing features to improve acceptance rate with insurance companies
• Reporting and analytics
• Compliance with the Health Insurance Portability and Accountability Act (HIPAA)
• Data encryption and security measures
• Technical support
• Revenue and claims management

Revenue cycle management

RCM is a complex and multifaceted process that requires close attention to detail and a deep understanding of the healthcare industry. It is essential for ensuring timely and accurate reimbursement for healthcare services rendered and can help improve efficiency, revenue, and patient satisfaction. By optimising their revenue streams through RCM, healthcare providers can achieve financial stability and provide better patient care.

Medical billing companies

Medical billing services can include:

• Provider enrollment
• Insurance verification
• Charge entry
• Claim submission
• Payment posting
• Account receivable management
• Denial management
• Appeal management
• Patient billing
• Reimbursement tracking
• Collection

Medical billing certification

Medical billing and coding are at the cornerstone of today's healthcare revenue system, ensuring that healthcare providers are reimbursed for their services. Medical billing and coding are two separate jobs, but they are often used together. Medical coders translate written copy—such as a doctor's diagnosis or patient prescriptions—into a numeric or alphanumeric code. Billing specialists then take this information and make a claim for the insurance company.

Medical Biller and Coder Requirements

There are no set educational requirements to become a medical biller and coder, but most employers require or encourage certification. Entry-level positions typically require the completion of a certificate and passing of a certification exam, or an associate degree in medical billing and coding.

Medical Biller and Coder Certification

Certification is not always necessary to work in this field, but it may help with employment prospects. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the US offer certificates or even associate degrees in the field.

The Certified Professional Coder (CPC) exam is the gold standard entry-level coding certification for physicians or professional fee coders. It is offered by the American Academy of Professional Coders (AAPC). The Certified Coding Associate (CCA) is an entry-level medical coding certification across all settings, offered by the American Health Information Management Association (AHIMA). The Certified Billing and Coding Specialist (CBCS) is currently an entry-level medical billing certification for physician practices, offered by the National Healthcareer Association (NHA).

Medical Biller and Coder Training

SJVC's online Medical Billing and Coding program offers a Certificate of Completion in as few as seven months or an Associate of Science degree in as few as 15 months. The program includes classes in medical insurance principles, patient registration and intake, and foundational medical office skills.

Medical Biller and Coder Career Opportunities

Medical billing and coding specialists earn an average annual salary of $40,350 and work in one of the fastest-growing professions. The US Bureau of Labor Statistics estimates that at least 27,000 new jobs will be needed in this profession by 2026.

Frequently asked questions