A medical bill starts with a patient coming into a healthcare facility or provider’s office for services. Doctors, nurses, specialists, or other medical staff provide examinations, tests, procedures or other care to the patient. Details about these services are written in the patient’s medical chart.
Codes for Medical Services
After the patient visit, medical coders read through the chart to identify all the services that were done. The people at Find-A-Code.com explain that every medical service has an ICD code that is used for billing purposes. ICD 11 codes provide information about the patient’s diagnosis and what services they received. Coders also determine the correct CPT code, which describes the specific medical service in more detail.
The Importance of Medical Coders
Medical coding is a specialized job that is extremely important to the healthcare industry. Coders must have an in-depth understanding of the highly complex ICD and CPT coding systems. Their coding work affects patient health records, provider payments and medical research data. Diligent coders ensure documentation and details are accurate before codes get submitted on claim forms. Coding errors can lead insurance companies to deny claims unfairly.
The Insurance Claim Form
All the coded information is put into an insurance claim form that gets sent to the patient’s health insurance company. The claim form has details like the patient’s name, birthdate, and insurance member number. It also includes codes about their diagnosis, medical services, and the costs involved. This claim form requests payment from the insurance company.
Insurance Company Review
When the insurance company gets the claim form, they first make sure all the patient, doctor, and medical details are correct. Then they determine what medical services they cover based on the patient’s specific insurance plan. They also check that the amount being charged matches their allowed payment amounts for those codes.
Insurance Payment Decision
The insurance company reviews all aspects of the claim carefully and then decides how much of the bill they will pay. Sometimes they decide not to pay for certain charges if they deem them unnecessary or not covered. The insurance payment is sent directly to the healthcare provider. Insurance companies explain the payment details to both the patient and the provider.
Patient Responsibility
After insurance pays its share, there may still be a remaining balance owed, which is the patient’s responsibility. This is because insurance doesn’t always cover 100% of medical costs. The patient gets a medical bill from the provider for whatever amount insurance did not cover. This is called the patient’s co-pay, deductible, coinsurance, or other terms for medical costs owed by the patient.
The Provider Payment Process
Healthcare facilities have billing departments that handle payments coming in for the services they provide. Payments may come from insurance companies first or directly from the patient. Patient payments might come in all at once or over an extended time with a payment plan. The billing staff tracks all payments and balances carefully to make sure the medical expenses get paid correctly.
Collections Efforts
Unfortunately, some patient balances go unpaid for a long time even after repeated bills get sent. After a certain timeframe or number of bills without payment, the remaining balance often gets sent to a collection’s agency. Having an unpaid medical bill in collections negatively affects someone’s credit score.
Conclusion
The complicated life cycle of medical billing has many players involved along the way, from the patient visit to the insurance payouts to final collections. Trained medical coding and billing staff manage the specifics of codes, claims and payments so providers can focus on quality healthcare services for their communities.
