Medical billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government-owned.
VCMBS enables medical practices to reduce their operational cost and hence improve the bottom line - by providing accurate and timely filing of claims, follow through on submitted claims and collections using state-of-the-art, award winning software technology.
Claims are filed electronically to eliminate errors at source, and speeds up claim processing for the insurance companies. As a result, amounts due to practitioners are collected on a timely basis. All appropriate reports would be provided to the practice in a timely manner. In addition, medical practices would have access to the computer system to run any available report - at any time - to check the status of any claim.
The billing process is an interaction between the provider and the insurance company (payer). It begins with the office visit. After the provider sees the patient, depending on the service provided and the examination, the doctor creates or updates the patient's medical record. This record contains a summary of treatment and demographic information related to the patient. Upon the first visit, the provider will usually give the patient a diagnosis (or possibly several diagnoses), in order to better coordinate and streamline his/her care.
The treatment, diagnosis, and duration of service combine to determine the procedure code that will be used to bill the insurance. The doctor then either provides this information to a medical coder or other billing specialist. From this, a billing record, either paper (usually on a standardized form called an HCFA) or electronic, is generated. This form includes the various diagnoses identified by numbers from the current ICD-9 manual.
This billing record or claim is then submitted either to a clearinghouse that acts as an intermediary for the information (this is typical for electronic billing) or directly to the insurance company. Some of the electronic transactions are sent via Electronic Data Interchange (EDI). The insurance company (payer) processes the claim. The insurance side of the process begins with testing the validity of the claim for payment.
The tests cover patient eligibility for payment, provider credentials, and medical necessity. Upon passing successfully the tests, the payer pays the claim. If a claim fails the tests, the payer rejects the claim and communicates the rejection message to the claim submission source. Upon receiving the rejection message, the provider must decipher the message, reconcile it with the original claim, make required corrections, and resubmit the claim again. This exchange of claims and messages may repeat multiple times until the claim is paid in full.
The frequency of rejections, denials, and underpayments is high (often reaching 50%)[citation needed], mainly because of high complexity of claims and data entry errors. Straight Through Billing technology, procedures, and training help manage the billing process to receive all payments on time.
