Physician billing services are the management of medical claims, on behalf of healthcare providers. These include coding diagnoses and procedures accurately, obtaining authorizations to fulfill healthcare regulations, following up on unpaid claims and answering patient billing inquiries. Quality physician billing services facilitate cash flow, reduce administrative burden, and dedicate more time to patient care.
Physician billing services can be performed by internal departments or external companies that manage the financial component of filing and following up on claims relative to medical billing. In this way, healthcare providers are paid in a timely fashion for the services they provide to their patients.
Medical billing is necessary to provide quality care to patients because it provides an acceptable income stream to create a quality patient experience and remain compliant. Professional physician billing services are now vital partners for practices to assist in the challenges they are navigating. This leads to reduced practice administration burden and delivers better financial results. Here are the steps of the billing process:
Vital steps of physician billing services:
1. Patient Eligibility Verification
The first step in the billing process involves the verification of the patient's insurance eligibility before the visit occurs. Verification involves making sure the patient has active coverage and benefits and that the expected appointment services are covered in their plan. Verifying eligibility is important, as it reduces the probability of claim denials and out-of-pocket expense for patients.
2. Coding and Charge Entry
Individuals with formal training in coding review the clinical documentation around the visit and then convert that into standard coding systems, including CPT, ICD-10, and HCPCS codes. Every diagnosis and every procedure needs to be coded accurately to reflect what happened during the patient’s visit. Once the code is created, the charge associated with each of the codes also needs to be assigned to appropriate charges and entered into the billing system.
3. Claims Submission
After the coding and charge entries, the claims can be submitted to the insurance payers. Claims can be submitted electronically or via paper format, depending on the payer used. Each claim needs to have proper patient and provider information, diagnosis and procedures, and charges associated with the claim. Timely and accurate submission of claims is essential in order to obtain timely and precise reimbursement. Errors may lead to delays in payment and denials.
4. Payment Posting
After payments are received from a patient or the patient's insurance company, they need to be accurately entered into the billing system. This involves reviewing Explanation of Benefit (EOB) statements or Electronic Remittance Advice (ERA) to confirm the payment amount and patient responsibility. Stringent payment posting will allow medical practices to track their revenue, outstanding patient balances, and keep their financial records healthy.
5. Denials and Appeals
Denied claims are a common occurrence in medical billing, and claims can be denied for various reasons. A denial can be caused by inaccurate codes, inadequate information, or an underwriting policy. The billing specialist will evaluate each denied claim, fix any mistakes, obtain any documentation required, and correct the bill and resubmit or file an appeal.
6. Follow-Up on A/R
Follow up on accounts receivable (A/R) deals with unpaid claims or underpaid claims. Medical billing teams will regularly evaluate aging reports to determine which patients' balances are due. The billing team may call the insurance company to find out the exact delay, or they may call the patient to verify that the insurance fulfills its obligation. Streamlined, repetitive follow-up on accounts receivable will increase collection rates, decrease outstanding receivable, & keep the business financially stable
Obstacles to Physician Billing Services
The practice of medical billing often presents obstacles and complications. It is important to have knowledge of the requirements of the individual payers and the applicable regulations, such as HIPAA and Medicare. Delays in payment, loss in revenue, or an audit can crop up if there is even a small coding error in documentation. The ever-increasing complexity of these issues makes the need for professional billing services even more necessary in modern practices.
1) Errors Resulting in Claim Denials
Claim denials often arise from errors in medical coding or incomplete documentation. Errors in coding can be as simple as using an out-of-date code, or coding for a patient for whom the practice had documentation, but was not the patient it was intended to code. Claim denial leads to additional administrative work, delayed payment, and reduced cash flow to the medical practice.
2) Delays in Reimbursement Cycles
Insurance companies do not always process reimbursements quickly. Slow reimbursement cycles create cash flow management issues for the practice, and the business takes great effort to cover expenses for daily operations, including payroll expenses, rent obligations, supplies, etc. To maintain the financial health of the practice, prompt submission and follow-up claims will maintain the flow of cash in an efficient manner.
3) Frequent Changes in Payer Policy
Insurance companies modify policies of coverage, documentation requirements, and payment rules. Not keeping up means claims may be denied, and revenue is lost. Practices must stay up to date so that payment processes can be updated to prevent compliance issues and issues collecting payments.
4) Compliance Risks and Penalties
Physicians must follow the strict rules set by Medicare and HIPAA otherwise non-compliance may lead to an audit, fines, or even legal challenges. Billing personnel must be trained on how to submit claims correctly and protect patients’ private information. Ensuring compliance protects the overall revenue of the practice.
How Professional Physician Billing Solutions Help
When billing is outsourced with professionals, the practice will have better performance and fewer issues with billing, to continue to operate better. Professional billing staff will ensure accuracy, timeliness, and compliance throughout the revenue cycle which can improve revenue and allow time for patient care.
1. Improved Revenue Cycle Management
Professional billing services are capable of managing the entire revenue cycle for a medical practice, from patient registration to final payment. They are experts in reducing claim denials, expediting reimbursements, and improving cash flow. Practices use to using professional billing teams often experience increased collection rates compared to an in-house staff without the particularized training.
2. Reduced Administrative Burden
When billing is handled in-house, it consumes time and resources. Physicians and staff are often working with their insurance companies for hours, wasting time they could be better using with patients. With the ability to outsource billing, time is freed up, staff burnout is lessened, and workflow is improved. It allows the medical team to focus on care for their patients.
3. Better Compliance and Less Error
Professional billing companies stay up to date with payer updates, regulatory changes, and updates to coding. They ensure claims are accurate and follow all rules and regulations about submitting claims. They will protect practices from costly audits, fines, and payment delays, movements that provide practices with peace of mind and sustained income.
4. Scalability and Flexibility
As a practice grows and develops, billing and its demand on the revenue cycle grow with it. Whether a practice is increasing the number of services offered, selecting more providers for hire, or opening more clinic locations, the correct professional billing service can scale with the practice. This means additional staff does not need to be hired, trained, or managed... a professional billing company can simply adjust services to meet the new demand for billing services.
Choosing a Physician Billing Company Wisely
When choosing the billing partner, make sure the company is HIPAA compliant, employs certified coders, and can provide a list of any qualifiers. The billing partner should provide a performance guarantee. Billing services for physicians are more than helpful. If you are outsourcing to a professional physician billing team, it allows you to work on high-quality patient care. Through outsourcing, providers can lower costs by as much as 80%, with hourly rates starting at $7. Vendors offer physician billing services tailored to their specialties as well as full end-to-end revenue cycle management. This allows physician practices to reduce their administrative burden, so they can spend more time on patient care.
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