7 Steps of a Medical Billing Process

PCS Revenue Cycle Management
PCS Revenue Cycle Management

If you are a healthcare provider and manage your medical billing process all on your own, you know how incredibly difficult it can be to do so alongside your other responsibilities. It can take quite a lot of time to process just one patient’s payment, and we’re sure you have so many others in line.

The entire medical billing process is slow, stressful, and simply not efficient. That’s why you can benefit from hiring a medical billing company to handle this essential yet secondary job. If you’re thinking they won’t be worth it and will make you do all the work anyway, let’s discuss how medical billers handle your medical billing for you in these seven steps.

1.   Registering the Patient

The entire process, of course, begins with the patient. It all starts when the patient first contacts or reaches out to the healthcare provider for an appointment.

If the patient is visiting for the first time, medical billers take all their information at this stage. This includes their demographic information, insurance details, medical history and reports, contact information, and anything else the medical biller deems necessary.

If the patient has already visited before, all the relevant information is saved, and there’s no need to go through the entire process again. However, the medical biller might still reconfirm some details, such as insurance policy, to make sure all the information is accurate.

It is quite crucial to record all this information accurately in this first step, as most of it is used in the following steps. Any incorrect details can result in a claim being denied, and the healthcare provider not being reimbursed.

2.   Insurance Authorization

This is another step that must be carried out correctly the first time, or  it can create a lot of trouble for everyone later on. After taking the patient’s history and reason for visit, medical billers need to check that against their insurance policy and make sure it is covered.

There are various health insurance providers out there, and each one has different insurance plans with different coverage. A patient might be coming in for an examination, thinking that the insurance will cover it when actually it is not included in the insurance plan.

Moreover, sometimes, insurance companies change their policies, so something covered before might not be covered now. Therefore, the medical biller checks and authorizes this beforehand to avoid confusion after everything is done.

In case the insurance company does not cover a particular procedure or prescription, the patient is notified that he will have to pay himself. Arizona drug rehab explains this well in this informative article.

3.   Checking In and Releasing the Patient

Checking in and releasing the patient is a pretty simple step. It involves asking the patient to fill in a few forms when he physically comes for his doctor consultation and confirms the information provided before.

This, too, could differ depending on whether it is the patient’s first visit or not. If it is his first visit, he might have to present some identification or other similar documents as well for verification purposes. After that, he is handed over to the doctor.

4.   Medical Coding

Not to sound like a broken record, but this is another vital step in the whole medical billing process and can play a significant role in determining whether a healthcare provider is compensated or not. In fact, this can even be divided into two separate steps because it’s that crucial.

However, we’ll keep things simple. After the patient is done visiting the doctor, all the details of his visit go to the medical coder. The medical coding team uses this information, such as the diagnosis, treatment, and any other service provided, and turns it into medical codes.

These medical codes, along with the patient’s information and other details, are contained in a document called the ‘superbill.’ This superbill eventually goes to the insurance company that can then easily understand everything the patient has undergone by reading the codes.

If the insurance company finds any discrepancy in these codes, they can deny the claim. Therefore, the medical coder spends extra time developing these codes as well as cross-checking them for accuracy. They also make sure they are compliant with the standards.

5.   Preparing and Submitting the Claim

Once the medical billers have the superbill containing the codes from the medical coders, they use it to prepare the claim. Different insurance companies demand different formats and procedures, so medical billers make sure that they prepare the claim accordingly.

The claim contains all the patient’s information as well as the total payment amount that the insurance company is expected to pay.

Most insurance companies require the claim to be sent electronically, so that is how the claim is submitted. If there is any error in the codes, or format of the claim, it is stopped at this stage.

6.   Managing Claim Adjudication

During this step, the insurance company evaluates the claim on their end. After reviewing the claim, it can be accepted, rejected, or denied. If it is accepted, it means the insurance company didn’t think there was anything wrong with the claim.

If it was rejected, it means that there was some error, which the medical billing company can correct and submit again. If it was denied, it means that the insurance company will not reimburse for those services, perhaps because it’s not part of their coverage.

7.   Posting Payment and Following Up with the Patient

After the claim is accepted, the insurance company releases the payment to the medical billing company. They check this payment against their own records, and if everything seems to be in order, they forward it to the healthcare provider.

Finally, they let the patient know of the payment details and notify them of any outstanding balance.


Since this is their entire job, you can count on medical billing companies to systematically and efficiently carry out the whole process, as you might have judged by the methodical steps explained above.

Moreover, relying on a medical billing company is great not just for reducing your workload and increasing your own work efficiency but also for improving your revenue cycles and profits. It’s a win-win situation, so we recommend consulting a medical billing company immediately.

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