How Does the Medical Billing Process Work?


Medical billing is when a healthcare provider submits medical claims for reimbursement from insurance companies for services rendered to patients. Medical billing and coding complexity includes creating claims, claim preparation, and medical coding, which involves determining the correct diagnosis codes for procedures performed. This leads to most physician practices employing a medical biller or back-end medical billing specialist to handle their medical billing and coding.

The entire process can be pretty complex, and several terms are commonly used about medical billing that may be unfamiliar to many people. We will provide an overview of how the process works and explain some of its most common terms.

How does medical billing work?

Medical billing is submitting and following up on the medical claims process with insurance companies to receive payment for services provided by healthcare providers. Medical billing can be complex and involve several steps, so it’s essential to understand the basics before you get started.


The first step in medical billing is submitting an insurance claim. This involves filling out claim forms that include information about the service, the patient’s insurance, and the provider’s contact information. Once the form is submitted, it’s processed by a billing company, which will submit it to the patient’s insurance company.


The insurance company will send payment to the billing company if the claim is approved, which will forward it to the provider. If the claim is denied, the billing company will work with the provider to submit an appeal.


The second step in medical billing is follow-up. This involves contacting the insurance company to ensure that they received the claim and that it was processed correctly. It also includes following up on denied insurance claims to ensure they’re being appropriately appealed.


Medical billing can be a complex process, but by understanding the basics, you can ensure that you submit claims properly and receive payment for your services.

The different stages of medical billing

Medical billing is a complex process that can involve several different steps. Generally, the process will involve the following stages:


1. The insurance verification process

2. The prior authorization (PA) process

3. The billing process itself

4. The collections process


Let us tackle each of these stages.


1. The insurance verification process is the first step in medical billing. This is when the insurance company verifies that the patient has coverage for the services they are seeking. It is crucial to remember that not all services are covered by insurance, and some services may require PA from the insurance company before they will be covered.


2. The PA process is when the insurance company determines whether or not a particular service is covered under the patient’s plan and whether or not it requires pre-approval before it can be provided. Not all services require PA, but for those that do, this is an essential step in medical billing.


3. The billing process begins once the service has been provided and the patient has been billed for it. This is when the bill goes to the insurance company for payment. It is crucial to remember that not all bills are paid by the insurance company – patients may have to pay a portion of the bill themselves.


4. The collections process happens after the bill has been sent to the insurance company and payment has not been received. This is when collection agencies may become involved to try and recoup some of the money owed.


Overall, medical billing can be a complex process and involves many different stages. Whether you are a patient seeking services, or a provider providing those services, it is essential to understand how this process works to ensure that all parties receive the care and compensation they deserve.

How to submit a claim for reimbursement

When you visit the doctor, the billing process begins. The first step is to submit a claim for reimbursement. This can be done in several ways:


1. Online: You can submit a claim through your insurance company’s website.


2. By phone: You can also submit a claim by phone. Simply call your insurance company and provide them with the information they need.


3. By mail: If you prefer, you can mail your claim to your insurance company. Be sure to include all the necessary information so your insurance claim can be processed accurately.


Once your claim is submitted, it will go through a series of reviews. This includes an insurance verification process and a PA process, if necessary. Your insurance company will then determine if the services you received are covered under your policy and, if so, how much of the cost will be reimbursed.


It can take time for your insurance company to review and process your claim, so be patient. In the meantime, you should save all your documentation related to the services you received, including receipts and invoices. This will help to make sure that there are little to no delays in getting reimbursed.


Medical billing terminology that you need to know

One of the most vital concepts to understand in medical billing is PA. PA is the process by which a health insurer decides whether or not a particular service is covered under a patient’s insurance plan. If a service requires PA, the patient must receive approval from the insurer before receiving the service.

Another critical concept to understand is insurance verification. Insurance verification is verifying that the services are covered by a patient’s insurance plan he or she is seeking. This process typically involves providing the insurer with information such as the patient’s name, insurance policy number, and service date.

In conclusion

The medical billing process can be confusing, and it can be helpful to understand how it works. By understanding some of the key terminology associated with medical billing, patients and providers can be better prepared to navigate the process and seek reimbursement for any services they have received or medical services rendered.

For a more convenient way of handling your medical billing, employ the services of Portiva’s virtual medical assistants. To learn more about our expertise, or at 800 991 6922.

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