Billing in the US is complicated, and that is not news to anyone who has dealt with healthcare administration. But most people don't see the actual process that happens behind the scenes when medical equipment gets ordered and billed.
There are basically two steps in the billing process, which include pre-billing and post-delivery billing. There are four steps in the pre-billing process which include order intake, physician communication, documentation follow-up, and order processing. The post delivery process includes billing process, claim submission, and resubmission.
As you can see, this process is difficult for healthcare staff to manage alongside patient care. Hence, you can seek help from outsourced medical billing services in that matter.
Step-by-Step Medical Billing Workflow
The billing process starts when an order or prescription is received from physicians, hospice agencies, or healthcare facilities. Sometimes the sales team initiates things after talking with a patient's family. The order might come through a website, over the phone, or get entered straight into Brightree.
Brightree is the software system that handles most of this billing hassles. Think of it as command central for tracking everything. Once the order is in, patient eligibility verification happens. This is checking whether the patient's insurance will actually pay for what's been ordered. You'd be surprised how often this step catches problems early.
The Prior Authorization Split
Not all orders need prior authorization, as some go straight through, but what about others? They need insurance company approval before anything can happen. For orders requiring authorization, things get more involved as someone must figure out exactly what documentation the insurance company wants. And they want specific things; not just any paperwork.
This means calling the physician's office more than once. Medical practices are swamped, and getting the right documents takes persistence. You need clinical notes, test results, and also sometimes very specific reports that justify why the patient needs this particular service.
All that gets compiled and sent to the insurance company, and then you wait. When authorization comes back approved, it goes into Brightree, and the process moves forward. Denials are a different story as they trigger a whole cycle of follow-up. More documentation, more calls, and more explanations about medical necessity. This keeps going until either approval happens or you find another route.
Claims Submission
Before claims go out, billing confirmation happens as everything gets double-checked. Sometimes claims need to be held. Maybe rental equipment is converting to purchase, or reauthorization might be due. Additional documentation could be missing, and these situations require careful tracking, so claims don't get forgotten.
Claims go out two ways, which include electronic EDI submissions or paper. Electronic is standard now because it's faster and you can track it, but some situations still require paper claims, which means longer waits and less visibility.
Third-party insurance and Medicaid each have their own submission processes due to different requirements. Claims get submitted and then the waiting starts again. However, it has been observed that the outsourced medical billing services are experts in this process.
Rejections vs Denials
Acknowledgements should come back confirming the payer received the claim, but acknowledgement doesn't mean approval. Then, three things can happen. The claim gets either paid, denied, or remains unresolved. Getting payment is obviously the goal as it comes through as an ERA (Electronic Remittance Advice) or EOB (Explanation of Benefits). The team posts the payment and moves toward closing out the account receivable.
Denials need investigation to understand the reasons. Those can be incorrect coding, missing documentation or the payer wants something else. Denial management is detective work, honestly. You figure out why it was rejected and what needs fixing.
Rejections are a bit different, and they happen when claims have errors that prevent processing entirely. Maybe a code is wrong or information is missing. The claim gets bounced back, and these get corrected and resubmitted. Finally, the whole cycle starts over.
Some claims just disappear, which leads to no payment, no denial, no rejection, nothing. This creates its own set of problems as following up with payers becomes necessary. This reconciliation work stops revenue from falling through the cracks.
Resubmission Realities
First-time claim success is not guaranteed as resubmission and reconciliation happen constantly. Corrected claims go back through submission, and the waiting process starts over. Follow-up continues with payers, patients, and physicians. Everything keeps moving toward resolution, but it rarely happens quickly.
Patient follow-up might involve collecting copays or explaining what insurance won't cover. Physician follow-up might seek additional documentation to support denied claims. Payer follow-up tackles questions about status, appeals denials, or resolves processing mistakes. All of this happens simultaneously across hundreds or thousands of claims.
So, you can see that it is not possible for the healthcare staff to deal with all these administrative hassles, otherwise patient care will get hampered. Here, you need the assistance of third-party experts.
How the Outsourced Medical Billing Services Help?
These third-party experts have the industry's highest productivity metrics and can reduce your operational costs by 80%. They also provide customized reporting according to the clients’ needs and dedicated account managers to make seamless communication.
These outsourced experts can reduce the AR bucket by 30% within a month and are 100% HIPAA compliant. These companies know how to work with clinic-specific EHR software like athenahealth, NextGen Healthcare, eClinicalWorks, and many more.
They also provide dedicated account managers and have no binding contracts according to the client’s needs. In case any issue occurs, these experts provide $1 million insurance coverage to the clinics and have less than two days of turnaround time.
Each of these experts tackle 50-55 patient demographic entry and 18-20 prior authorization requests in a single day. Moreover, they manage denials for 30-35 claims and take 50-55 calls for patient appointment queries, scheduling patient appointments, voicemail response, and many more.
So, if you want to streamline your billing process, it can be a feasible option to take the help of outsourced medical billing services in that matter.
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