Medical Billing and Coding in Michigan

How Our Medical Billing and Coding Process Works

1. Confirming the Validity of the Patient’s Insurance

• Verification. Gather comprehensive insurance details from the patient, including photographs of both sides of their insurance card and any other necessary information.
• Eligibility Check. Verify the current status and coverage of the insurance plan using phone or online platforms.
• Benefits Verification. Understand the specifics of the plan’s coverage, such as co-pays, co-insurance, deductibles, and any required pre-authorizations or referrals.
• Document Results. Record all collected verification details in the patient’s records for future reference.

2. Scheduling an Appointment With the Provider

• Patient Information. Confirm or obtain the patient’s demographic details and medical history.
• Appointment Booking. Use the practice management system to schedule appointments based on the provider’s availability.
• Reminders. Send out reminders via phone, email, or text to reduce the possibility of no-shows.

3. Delivering Care (First Occurrence)

• Patient Check-In. Update the patient’s personal and insurance information at the reception.
• Consultation. The provider assesses the patient and formulates a diagnosis and treatment plan.
• Service Documentation. Record all services and procedures performed during the patient’s visit.

4. Updating Details in the EMR

• EMR Entry. Input details from the visit into the Electronic Medical Records system, including the patient’s medical history, diagnostics, and procedure notes.
• Code Assignment Preparation. Confirm documentation is accurate and comprehensive to aid in correct coding.

5. Practice Support Identifies the Codes

• Medical Coders. Certified coders review EMR data to assign the appropriate ICD, CPT, and HCPCS codes.
• Accuracy Check. Verify that the assigned codes accurately reflect the services provided and adhere to payer guidelines.

6. Delivering Care (Second Occurrence, If Needed)

• Follow-Up Appointments. Schedule any necessary follow-up visits to maintain continuity of care.
• Continuation of Care. Thoroughly document follow-up visits to include all services rendered.

7. Claim Submission

• Claim Preparation. Compile detailed patient and service data for processing claims.
• Claim Validation. Employ claim scrubber tools to detect and address potential errors before submission.
• Electronic Submission. Submit the claim electronically through data interchange (EDI) or a clearinghouse.
• Submission Confirmation. Record the confirmation receipt upon submitting the claim.

8. Claim Processing

• Payer Review. The insurance payer reviews the claim for accuracy and eligibility.
• Determination. The payer decides whether to approve, partially deny, or fully reject the claim.
• Explanation of Benefits (EOB). Receive and log the EOB to capture the payer’s decision regarding the claim.

9. Payment Posting

• Receive Payment. Collect payments from both the insurance payer and any patient balances.
• Post Payments. Enter the payment details into the practice management system and update the patient’s account.
• Adjust Account Balances. Apply necessary adjustments according to agreements and update any remaining patient balances.

10. Follow-Up

• Denial Management. Investigate reasons for denied or underpaid claims and take steps for resubmission or appeal when necessary.
• Patient Billing. Issue billing statements for balances due and follow up on overdue accounts.
• Customer Service. Address any questions or concerns from patients or payers regarding billing or services provided.

11. Reporting and Analysis

• Operational Reports. Generate reports providing details on claim statuses, denials, payments, and accounts receivable to monitor financial health.
• Performance Analysis. Evaluate the efficiency of coding, billing, and collection processes to identify areas for improvement.
• Compliance Audits. Conduct regular internal audits to confirm conformity with billing and coding regulations.