Medical billing

Medical billing is a payment practice within the United States health system. The process involves a healthcare provider submitting, following up on, and appealing claims with health insurance companies in order to receive payment for services rendered; such as testing, treatments, and procedures.

Overview

The same process is used for most insurance companies, whether they are private companies or government-sponsored programs. Medical billers are encouraged, but not required, to become certified by taking an exam such as the CMRS Exam, RHIA Exam, CPB Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field.

Process

The medical billing process is an interaction between a healthcare provider and the insurance company (payer). This entire process is known as the billing cycle. It can take anywhere from several days to several months to complete and require several interactions before a resolution is reached.

Billing Cycle

The billing cycle is a series of steps that include the following:

1. Patient check-in
2. Check out
3. Superbill creation
4. Medical coding
5. Charge entry
6. Claim submission
7. Payment posting
8. Accounts receivable follow-up
9. Final resolution

Medical Coding

Medical coding reports what the diagnosis and treatment were, and prices are applied accordingly. Medical coders generally use the International Classification of Diseases (ICD) coding system to identify the diagnosis. A similar system, the Current Procedural Terminology (CPT), is used to identify the treatment.

Challenges

Medical billing has been plagued with problems and complexities. The complexities include dealing with multiple payers, following multiple procedures and laws, and handling a variety of payment models.

See Also

• Health insurance in the United States
• Medical coding
• International Classification of Diseases
• Current Procedural Terminology

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