Medical Billing and Coding in Illinois

Our Medical Billing and Coding Process

1. Confirm the Validity of the Patient’s Insurance

• Verification. Collect the patient’s insurance information, including both sides of their insurance card and any necessary identification details.
• Eligibility Check. Reach out to the insurance provider via phone or online portal to verify that the insurance plan is active and covers the scheduled services.
• Benefits Verification. Ascertain what the patient’s insurance plan covers, including co-pays, co-insurance, deductibles, and whether pre-authorization or a referral is required.
• Document Results. Record all verified insurance details in the patient records for future reference.

2. Schedule an Appointment With the Provider

• Patient Information. Gather or confirm the patient’s demographic and medical history.
• Appointment Booking. Utilize the practice management system to schedule an appointment based on the provider’s availability.
• Reminders. Send appointment reminders via phone, email, or text to minimize no-show rates.

3. Deliver Care (First Occurrence)

• Patient Check-In. Confirm and update the patient’s personal and insurance details at reception. Accurate details at this stage are critical for successful medical coding in Illinois.
• Consultation. The provider examines the patient and formulates a diagnosis and treatment plan.
• Service Documentation. Document all services and procedures performed during the visit.

4. Update Details in the EMR

• EMR Entry. Input visit details, including history, diagnostics, treatment plans, and procedure notes, into the Electronic Medical Records (EMR) system.
• Code Assignment Preparation. Ensure documentation is complete and accurate to support subsequent coding.

5. Practice Support Identifies the Codes

• Medical Coders. Certified medical coders review EMR data to translate documented services and diagnoses into appropriate ICD, CPT, and HCPCS codes.
• Accuracy Check. Verify that medical codes accurately reflect the services provided and comply with payer policies.

6. Deliver Care (Second Occurrence, if Needed)

• Follow-Up Appointments. Schedule additional visits if further examination, treatment, or monitoring is necessary.
• Continuation of Care. Document these follow-up visits as precisely as the initial ones to ensure all delivered services are recorded.

7. Claim Submission

• Claim Preparation. Compile the claim with comprehensive patient information, insurance details, diagnosis and procedure codes, and charges.
• Claim Validation. Use a claim scrubber tool to identify potential errors.
• Electronic Submission. Submit the claim to the insurance payer via electronic data interchange (EDI) or clearinghouse.
• Submission Confirmation. Receive and document a confirmation receipt verifying claim submission.

8. Claim Processing

• Payer Review. The insurance payer reviews the claim for accuracy, eligibility, and policy compliance.
• Determination. The payer decides whether to approve, partially deny, or reject the claim fully.
• Explanation of Benefits (EOB). The payer sends an EOB or remittance advice outlining the decision and payments made.

9. Payment Posting

• Receive Payment. Collect payments from the insurance payer and corresponding patient payments.
• Post Payments. Record payments in the practice management system, updating the patient account and EOB.
• Adjust Account Balances. Apply necessary adjustments based on contractual agreements and post the remaining balances due from the patient.

10. Follow-Up

• Denial Management. Review reasons for denied or underpaid claims, gather additional documentation if needed, and resubmit or appeal.
• Patient Billing. Send statements to patients for balances they owe and follow up on overdue accounts.
• Customer Service. Address questions or concerns from patients or payers about the bill or services received.

11. Reporting and Analysis

• Operational Reports. Generate reports on claim submission statuses, denials, payment postings, and accounts receivables to monitor financial health.
• Performance Analysis. Assess coding, billing, and collection efficiency, identifying areas for improvement.
• Compliance Audits. Conduct regular internal audits to ensure adherence to medical billing and coding regulations, making necessary adjustments to maintain compliance.