Deals with the financial aspects of medical services provided, including billing patients and insurance companies. It is included in the support processes.
High level description #
Subprocesses #
Patient Registration #
The process begins with patient registration, where basic demographic and insurance information is collected. This step is crucial for setting up a patient file that will be used throughout the billing process.
Activities and estimated duration #
Collect Demographic and Insurance Information
Gather basic demographic details and insurance information from the patient. Approximately 5-10 minutes per patient.
Create Patient File
Generate a patient file with the collected information. Approximately 1-2 minutes.
Verification of Insurance Coverage #
Hospital staff spend significant time verifying insurance coverage to understand the financial responsibility for the visit. This involves determining which procedures and services are covered by the patient’s insurance and informing patients about potential out-of-pocket costs for uncovered services.
Activities and estimated duration #
Verify Insurance Coverage
Confirm the insurance coverage details of the patient. Approximately 5-15 minutes per patient.
Determine Coverage for Procedures and Services
Assess which medical procedures and services are covered by the patient’s insurance plan. Approximately 10-30 minutes per patient.
Inform Patient About Coverage and Potential Costs
Communicate to the patient the details of their insurance coverage and any potential out-of-pocket costs for uncovered services. Approximately 5-10 minutes per patient.
Superbill Creation #
After the patient’s visit, medical reports are translated into diagnosis and procedure codes by a medical coder. A superbill is then compiled, including provider information, patient demographic and medical history, and the coded procedures and services performed.
Activities and estimated duration #
Translate Medical Reports to Codes
Translate medical reports into diagnosis and procedure codes. Approximately 10-30 minutes per patient.
Collect Provider Information
Gather provider information, including name, address, and identification number. Approximately 5-10 minutes per patient.
Collect Patient Demographic Information
Gather patient demographic information, such as name, date of birth, and address. Approximately 5-10 minutes per patient.
Collect Patient Medical History
Gather patient medical history, including prior medical conditions, allergies, and prescribed medications. Approximately 10-20 minutes per patient.
Compile Superbill
Compile a *superbill containing provider information, patient demographic and medical history, and coded procedures and services performed. Approximately 15-30 minutes per patient.
*Superbill: document made for insurance companies. It details the services a therapist or health care provider performed for a client. It is a receipt for a visit to the doctor’s office, containing vital information (diagnosis and procedure codes, etc.) needed for insurance payers to reimburse the patient for the services after they have paid. They’re different from regular medical bills in that insurers use them to pay patients rather than providers.
Claims Generation and Submission #
The medical biller uses the superbill to prepare a medical claim, which is then carefully reviewed for accuracy and compliance with payer and HIPAA standards. The claim is submitted to the patient’s insurance company, often through a clearinghouse that acts as a liaison between healthcare providers and insurers.
Activities and estimated duration #
Prepare Medical Claim
Create a medical claim using the superbill generated from the patient’s visit. Approximately 15-30 minutes per claim.
Review Claim for Accuracy
Thoroughly review the medical claim to ensure accuracy and compliance with payer and HIPAA standards. Approximately 10-20 minutes per claim.
Submit Claim to Insurance Company
Transmit the reviewed medical claim to the patient’s insurance company. Approximately 5-15 minutes per claim.
Monitoring Claim Adjudication #
Adjudication is the process by which insurance companies evaluate claims to determine their validity and the amount of reimbursement. Claims may be accepted, rejected, or denied, with rejected claims requiring correction and resubmission.
Activities and estimated duration #
Check Claim Status
Verify the status of the medical claim to determine if it has been adjudicated. Approximately 5-10 minutes per claim.
Is Claim Adjudicated?
Make a decision based on whether the claim has been adjudicated or not. Instantaneous decision based on the claim status.
Review Rejected Claim
Review a rejected medical claim to identify issues and take necessary actions for correction and resubmission. Approximately 10-30 minutes per claim.
Review Accepted Claim
Review an accepted medical claim to ensure accuracy and completeness. Approximately 5-15 minutes per claim.
Patient Statement Preparation and Follow-Up #
Once the claim has been processed, the patient is billed for any outstanding charges. Medical billers must follow up with patients whose bills are delinquent and, if necessary, send accounts to collection agencies.
Activities and estimated duration #
Prepare Patient Statement
Generate a statement detailing the patient’s outstanding charges once the claim has been processed. Approximately 5-15 minutes per statement.
Follow-Up on Delinquent Accounts
Contact patients with delinquent accounts to remind them of outstanding payments. Approximately 5-10 minutes per account.
Send Accounts to Collections
Transfer accounts of patients with persistently delinquent payments to collection agencies for further action. Approximately 15-30 minutes per account.
Utilization of Technology #
To minimize errors and administrative costs, many hospitals invest in training for billing and coding staff, implement efficient billing processes such as electronic billing and automated claim submission, and use accurate and up-to-date billing software. These measures help to streamline the billing process, reduce errors, and improve revenue.
Activities and estimated duration #
Staff Training
Provide training to billing and coding staff to effectively use new technologies. Approximately from a few hours to a few days.
Implement Efficient Processes
Implement efficient billing processes such as electronic billing and automated claim submission. Approximately from a few days to a few weeks.
Implement Billing Software
Implement accurate and up-to-date billing software to improve accuracy and efficiency in the billing process. Approximately from a few weeks to a few months.
Compliance and Quality Assurance #
The billing process involves meticulous adherence to coding processes governed by compliance standards like ICD-10 and CPT. An accurate coding and medical billing process ensures compliance with regulatory frameworks and enhances the precision of billing.
Activities and estimated duration #
Adhere to Coding Processes
Ensure meticulous adherence to coding processes governed by compliance standards like ICD-10 and CPT. Approximately from a few hours to a few days.
Quality Assurance Check
Perform a quality assurance check to ensure accuracy and compliance with regulatory frameworks. Approximately from a few hours to a few days.
Follow-Up on Non-Compliance
Conduct follow-up procedures to address identified non-compliance issues and ensure resolution. Approximately from a few days to several weeks.
Interaction with Insurance Companies #
The interaction between medical billers and insurance companies involves submitting claims, validating information, and addressing discrepancies. This collaboration is essential for timely reimbursement and plays a pivotal role in optimizing revenue.
Activities and estimated duration #
Submit Claims
Submit claims to insurance companies for reimbursement. Approximately from hours to days.
Validate Information
Validate the information provided by insurance companies, ensuring accuracy and completeness. Approximately hours to days.
Address Discrepancies
Address any discrepancies identified during the validation process, ensuring alignment between submitted claims and insurance company requirements. Approximately hours to days.
Atributtes #
Staff #
- Highly trained personnel in medical billing and deep knowledge of medical coding procedures.
- Specialists in claims management and dealing with insurance companies.
- Personnel with effective communication skills to address discrepancies and solve problems proactively.
- Possibly, an internal audit team to ensure accuracy and regulatory compliance throughout the billing process.
Material #
- Access to specialized software in medical billing and claims management to streamline processes and ensure accuracy.
- Detailed documentation of billing policies and procedures, as well as access to the latest updates in billing codes and government regulations.
Method #
- Implementation of clear and efficient standard operating procedures (SOP) for each stage of the billing process, from claim submission to discrepancy tracking.
- Development of clear and effective communication protocols to interact with insurance companies and resolve issues in a timely manner.
Machine #
- Modern computer equipment and updated software to process claims efficiently and accurately.
- Access to patient databases and electronic medical records to ensure information accuracy when submitting claims.
- Possibly, the implementation of artificial intelligence or machine learning systems to analyze data and improve accuracy in billing and coding.
Usual Loops #
Downloads #
BPMN graphs #
Download the collapsed BPMN diagram.
Download the expanded BPMN diagram.
Use Case #
In this use case, there is an important difference on the number of billing technician among the three hospitals. All of the hospitals present some outdated patient’s medical gistory, with their corresponding claims. One of them (Hospital 1) presents a non-updated billing software. Also, dependinding on the type of insurance (medicare, medicaid, private), there’s a major probability of claims being rejected.
The recommended software is the Inverbis Healthcare platform.
Scientific source
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