Medical Billing and Coding in Missouri

Practice Support’s Medical Billing and Coding Process

1. Confirming the Validity of the Patient’s Insurance

• Verification. Collect comprehensive insurance details from the patient, including photographs of both sides of their insurance card and any other necessary information.
• Eligibility Check. Validate the current status and coverage of the insurance plan via telephone or an online platform.
• Benefits Verification. Know the specifics of the plan’s coverage, such as co-pays, co-insurance, deductibles, and any needed pre-authorizations or referrals.
• Document Results. Record all verification details in the patient’s records for future reference.

2. Scheduling an Appointment With the Provider

• Patient Information. Confirm or gather the patient’s demographic information and medical history.
• Appointment Booking. Schedule the appointment using the practice management system based on the provider’s schedule.
• Reminders. Send reminders through phone, email, or text messages to reduce the likelihood of no-shows.

3. Delivering Care (First Occurrence)

• Patient Check-In. Update the patient’s personal and insurance information at the reception area.
• Consultation. The provider evaluates the patient and develops 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. Ensure 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. Confirm that the assigned codes correctly 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 ensure continuity of care.
• Continuation of Care. Completely document follow-up visits to ensure all services are recorded.

7. Claim Submission

• Claim Preparation. Compile detailed patient and service data for the claims process.
• Claim Validation. Use claim scrubber tools to detect and resolve potential errors before submission.
• Electronic Submission. Submit the claim through electronic data interchange (EDI) or a clearinghouse.
• Submission Confirmation. Record the confirmation receipt upon submission of the claim.

8. Claim Processing

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

9. Payment Posting

• Receive Payment. Collect payments from the insurance payer and any balances due from patients.
• Post Payments. Enter the payment information 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 the reasons for denied or underpaid claims and take steps to resubmit or appeal as needed.
• Patient Billing. Send 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 the services provided.

11. Reporting and Analysis

• Operational Reports. Generate reports that provide details on claim statuses, denials, payments, and accounts receivable to monitor financial health.
• Performance Analysis. Assess the efficiency of coding, billing, and collection processes to identify potential improvements.
• Compliance Audits. Conduct regular internal audits to ensure conformity with billing and coding regulations.