According to a report published by the American Hospital Association, around 25% of hospitals lose
money overall every year. Among them, approximately 68% incur a loss for Medicare billing itself!
Billing in healthcare is a highly complex process. Only professional billers with updated knowledge
and relevant skills can tackle the healthcare industry’s issues right now. However, it is difficult
for every health organization to hire a comprehensive team of individuals, let alone hire
specialists! In this scenario, it is crucial for medical organizations to up skill their workers or
outsource the entire process to companies with proficient billers.
This article will take you through the top know-hows that the professionals in your billing team
must get used to. Read on to know more.
1.Breaking Down the Steps of Billing in Healthcare:
Breaking down the different steps of billing in healthcare can help you to simplify the complex
procedure. They might seem basic, but you need to pay keen attention to each one of the steps to
improve your cash flow.
Patient Registration: Patient registration is the first and one of the most crucial steps of medical
billing. During this step, you must note down all relevant information related to the patient along
with the insurance details.
Pre-Authorization: In some cases, the provider or the organization staff might need to get in touch
with the insurance company before performing certain procedures. This is done to ensure that the
insurance company will reimburse the provider for some particular procedures or the treatment plan
of the patient.
Coding the Procedures:This step takes place after the provider checks the patient and prepares a
treatment plan for the diagnosis. The medical coder takes the diagnosis and other performed
procedures and codes them according to the relevant Government guidelines to prepare the
‘superbill.’
Preparing and Filing Claims: The medical biller assigns the required charge to the ‘superbill’
components. During this step, the biller should be vigilant about the codes assigned and the
formatting used to ensure that the claim is clean. Once it is done, the biller files the claim with
the respective insurance company.
Following Up with Insurance Payers: Once filed, the insurance payers go thoroughly through the
claims. This process takes up some time. Therefore the billing team needs to follow up with them
regularly. If the claim is clean and in adherence to their guidelines, the insurance company
reimburses the verifiedamount.
Collecting Out-of-Pocket Expenses: The bill amount in excess of what the insurance company pays is
the responsibility of the patient. The billing team should send the required documents to the
patients and contact them via call, email, or text message to collect the pending charge.
2.Components of a Clean Claim:
The points discussed above are only helpful if the claims are clean. However, this is the step where
the team goes wrong. Any mismatching components in the claim lead to denial or rejection, which
causes an unnecessary delay in revenue flow. Make sure the filed claims are clean. Here are a few
vital components:
Precise demographic details of the patient
Provider details
NPI number of the provider
Federal Tax ID of the provider
Indicating any case of emergency (EMG)
Updated Diagnosis Codes (ICD)
Updated codes for procedures and any modifiers, if applicable (CPT, HCPCS)
Individual charges for every listed procedure or medical service
Total charges of the entire procedure
Medical facility details (Name, Full Address)
Date of service
3.Hospital v/s Physician Billing in Healthcare:
Hospital billing and physician billing are different areas, and therefore each needs the expertise
of various professionals.Keep the following points in mind:
Hospital Billing:
Firstly, hospital billing is a much more complicated process than physician billing. It has a
significantly more number of components that billers should track adequately.
Billers use the UB-04 form in the case of paper-based bills. In the case of electronic billing, they
use the 837-I form.
Institutional coders and billers need to perform specific duties due to the sheer volume of
patients.
Hospitals also need to hire coders and billers experienced in billing different medical specialties
due to the variety of specialists working in a hospital setup.
Physician Billing:
Physician billing is more straightforward as compared to institutional billing.
Billers have to use form CMS-1500 for paper-based bills, while in the case of electronic billing, it
should be 837-P.
A billing team in a physician’s office often needs to perform billing, coding, and administrative
duties interchangeably.
Nevertheless, to ensure claims are clean, billers should be competent enough to handle the entire
billing procedure properly.
4.Areas of Improvement:
Billing in healthcare is undergoing many changes to ensure that the organization’s revenue cycle is
strong, there are lesser delays from the insurance companies, and there are lesser burdens on the
patient. However, there are still some areas that could use some improvement:
Switching to Automation:
A great many work hours are wasted to perform steps of billing in healthcare manually. Time can be
used more efficiently with the help of automated systems.
A recent study by CAQH revealed that while rates of automated claim submission, remittance advice,
and eligibility verification procedures, among others, went up, rates of use of automation for
payments went down.
Providers can save around USD 9 Billion every year with the help of automation.
Increasing Patient-Provider Transparency:
Providers should be more transparent with the patients when it comes to financial responsibility.
A survey conducted by West revealed that around 35% of providers do not discuss finances with the
patients at all.
It also said that only about one-fifth of providers discuss the costs of the services with the
patients.
Increasing provider-patient transparency will help the billing teams collect the revenue from the
patients without delay and automatically improve the cash flow.
Fast Tracking Physician Query:
Coders need to consult the physicians regarding any confusion in the services rendered before
preparing the ‘superbill.’
This process is unnecessarily delayed since there is no direct communication. It passes through
several desks before it reaches the provider.
With a simple mobile-friendly system in place, the coders can directly communicate with the
physicians and get the necessary information.
A similar system at Western Maryland Health Systemhelped to get down four days to just four hours!
5.Is outsourcing a good option for billing in healthcare?
Many healthcare providers prefer to outsource their billing work to
leading revenue cycle management companies. The reasons
are:
Signing a contract with the RCM company makes them accountable for performing their duties
diligently.
With HIPAA compliance, they take ample measures to make sure that sensitive patient information is
not compromised.
With their teams of professionals handling your day-to-day billing work, you can engage your
workforce to tackle more complicated administrative work.
You need not invest too many financial resources in the latest technology. The outsourcing company
will ensure that the claims are clean by running them through the latest software tools.
Did these tips help you to understand billing in healthcare better? Write down your queries below,
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