top of page
  • Eva Ahlawat

10 Important Steps of Medical Billing in Revenue Cycle Management

Medical Billing Steps in Revenue cycle management

Medical billing is a crucially important component of the revenue cycle management (RCM) that ensures on-time and precise payments to healthcare providers from medical insurance companies for their services. It is a multi-phase endeavor that demands a disciplined and thorough approach and compliance with rules and regulations. In this article, we will review the ten vital aspects of medical billing in the revenue cycle management process starting from registration of patients through account posting and reconciliation. In addition, we will also explore medical coding accuracy standards, techniques that help in efficient claims denial management and need for communicating the medical billing in simple and understandable manner to patients. Let's dive in!

  1. Patient Registration and Insurance Verification: Patient registration and insurance verification are the steppingstones of the most crucial process of medical billing. This includes collecting all the patient information necessary by inputting the details like name and contact, insurance, and demographics. Consequently, healthcare givers need to establish whether the information provided is from authorized insurance companies and in line with the patient’s coverage to avoid under- or overbilling. Such a step allows the rejection of claims to evade and simplifies the billing process.

  2. Medical Coding and Charge Capture: Adequate medical coding is important, considering proper providers' reimbursement and revenue cycle management. Medical teams utilize the American list of Procedural Terminology as well as International Classification of Diseases (CPT and ICD) to translate non-numerical medical codes into numbers, and vice versa. The old set of codes are important because they are used for the submission of claims, the collection of reimbursements, and the statistical analysis. Charge capture means exactly that - registering all services rendered to the patient and submitting them with the related codes attached to them.

  3. Healthcare Claims Submission: After the claims have been coded, either the provider or the health insurance company submits them for reimbursement. This phase involves reporting and submission of electronic or paper claims by providing the records and supporting documents to include diagnostic reports, itemized billing statements, and other clearance documents. Preparation and ordering of insurance claims must be in line with the specific rules and requirements of every insurance company or payer to allow for prompt and correct processing.

  4. Claims Adjudication and Denial Management: Following submission of claims, the insurers or payers go through a process known as claims adjudication where the claims are verified. The main objective of claims adjudication is to ensure that the claims are in line with the policy and therefore worthy of being paid for by the insurance companies. This procedure involves assessing the health care services required for approval based on evidential data and compliance with insurance coverage policies. Claim denial requires a powerful denial management strategy, which includes explaining the claim for denial, if necessary, and the appeals as well as re-submission of the claim with the required corrections or additional information if it is denied. Critical denial management is imperative for seeking maximum reimbursements and avoiding revenue loss.

  5. Patient Billing and Collections: Once claims are acknowledged and paid, physicians prepare billing or statements which provide the extent of the services delivered, health insurance coverage and the patient's financial contribution. Such statements should be straightforward, succinct, and patient-friendly to increase the understanding rate and to accelerate the payment. The providers of patients’ medical services also build up effective techniques of obtaining patients’ compensation purposefully in a timely manner which would give a possibility of offering a part-payment plan or turning to the third-party collection agencies if there will be need.

  6. Payment Posting and Reconciliation: The transactions that payment posting, and reconciliation involve are recording and match the patient's insurance companies and accounts with the corresponding claims and claims. This procedure is designed to guarantee infallible bookkeeping and to trace any dissimilarities or unaccounted sums. As it is a dual control system, it also highlights the deductions or overpayments in addition to detecting the payment issue that requires adjustments.

  7. Revenue Cycle Reporting and Analysis: Tracking and measuring revenue cycle is an important step in understanding the trends, improvement needs, and also any possibility of revenue loss. Medical specialists should be engaged in generating periodic comprehensive reports and analyzing the most important KPIs with relation to the revenue cycle like denial rates, average reimbursement time, and collection rates. They direct deductions of this knowledge to the process of revenue cycle management and, as a consequence, contribute to the effective execution of the financial plan.

  8. Medical Coding Accuracy Guidelines: Accurate medical coding provides a basis for valid submission of claims and successful medical billing. Medical coding specialists should follow medical coding accuracy guidelines that include among others selecting the adequate codes to be assigned based on documented services and diagnosis, using the specific code set and adhering (to) the latest coding principles and standards as they change. The coders should follow the right policies and rules of documentation, and there should be clear communication between healthcare providers and coders to achieve accurate coding.

  9. Healthcare Claims Clearinghouse: According to the ACA (Affordable Care Act), healthcare claims clearinghouse is the third-party assistance that works as a communicator between medical providers and insurance companies or payers. It receives electronic submissions from the healthcare providers passing them through the validation of errors or missing information and routes them to the appropriate insurer for processing. Using the Healthcare Claims Clearinghouse will minimize the submissions of claims, the rate of errors, and the efficiency of the process.

  10. Clean Claim Submission: Claims verification remains the focal point in reducing claim denials and attaining speedy payment. A valid claim, on the other hand, is one that is precise, comprehensive, and fully complex with all the components and criteria of the insurance company or payer. Healthcare specialists should check claims for missing information, mistakes, and adherence to coverage policies and only after that can health care providers send claims. Scheduled audits and standard performance assessment tools can be helpful in elevating the bill accuracy rates.

A Step-by-Step Guide to Patient Registration and Insurance Verification in Medical Billing

Patient registration and insurance verification are critical steps in the medical billing process. Let's explore a step-by-step guide to ensure a smooth registration and verification process:

  1. Collect Patient Information: Collect the patient’s vital details like the name, contact details, date of birth, social security number, and insurance information.

  2. Verify Insurance Eligibility: Employ online resources or contact the insurance company directly to check on the patient's insurance coverage, eligibility, and any prior approval necessary.

  3. Document Insurance Details: Get the insurance policy number, group number, and anything else like co-pays, deductibles, and limitation of coverage indicated.

  4. Capture Demographic Information: Determine the demographic features like the patient's address, employment details, and emergency contact details.

  5. Obtain Consent and Authorization: Make certain that the patient has all the necessary consent forms signed, including ones for billing, privacy, and release of medical information.

  6. Communicate Financial Responsibility: Make your patient well-informed by reporting the financial responsibility he/she has, which includes co-pays, deductibles, and any out-of-pocket costs.

  7. Educate Patients on Insurance Coverage: Help patients to acquire knowledge about their insurance coverage, for example, any limited services, network providers or pre-authorizations requirements.

  8. Verify Additional Coverage: If the patient possesses a second or a third coverage policy, verify the details and coordinate the payment methods with the primary insurance.

  9. Update Electronic Health Records (EHR): Ensure the complete and correct entry of the collected data into the patient's electronic health records to ensure the tie-ins.

  10. Review and Update Regularly: Regularly revise and update patient data and insurance coverage, so as to confirm the accuracy of the bill and the claims completion.

EvolveBPO: Your Trusted Partner for US Healthcare RCM Services

Maximize your revenue and optimize your operations with EvolveBPO's comprehensive RCM solutions for US healthcare providers. From medical billing and coding to claims processing and patient engagement, we provide customized solutions to enhance your revenue cycle.


bottom of page