Medical Billing and Coding in North Carolina

Our North Carolina Medical Billing and Coding Process

1. Confirming the Validity of the Patient’s Insurance

• Verification. Collect the patient’s insurance information, including images of both sides of the insurance card and any additional requisite details.
• Eligibility Check. Use phone or online resources to confirm the current status and coverage of the insurance policy.
• Benefits Verification. Understand the plan’s specific coverage elements, such as co-pays, co-insurance, deductibles, and any needed pre-authorizations or referrals.
• Document Results. Record all gathered verification information in the patient’s records for future reference.

2. Scheduling an Appointment With the Provider

• Patient Information. Confirm or obtain necessary demographic information and medical history of the patient.
• Appointment Booking. Utilize the practice management system to schedule appointments in accordance with the provider’s availability.
• Reminders. Issue reminders through phone, email, or text to reduce the rate of no-shows.

3. Delivering Care (First Occurrence)

• Patient Check-In. Update the patient’s personal details and insurance information upon arrival.
• Consultation. The provider assesses the patient and develops a diagnosis and treatment plan.
• Service Documentation. Document all services and procedures provided during the patient’s visit.

4. Updating Details in the EMR

• EMR Entry. Input visit details into the Electronic Medical Records system, including the patient’s medical history, diagnostic information, and procedure notes.
• Code Assignment Preparation. Confirm that documentation is complete and precise to achieve accurate coding.

5. Practice Support Identifies the Codes

• Medical Coders. Certified coders review EMR data to assign appropriate ICD, CPT, and HCPCS codes.
• Accuracy Check. Ensure the assigned codes accurately represent the services provided and comply with 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. Meticulously document follow-up visits, capturing all services rendered.

7. Claim Submission

• Claim Preparation. Collate detailed patient and service data for processing claims.
• Claim Validation. Utilize claim scrubber tools to detect and correct potential errors before submission.
• Electronic Submission. Submit the claim electronically via data interchange (EDI) or a clearinghouse.
• Submission Confirmation. Record receipt confirmation once the claim is submitted.

8. Claim Processing

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

9. Payment Posting

• Receive Payment. Accept payments from the insurance payer and any patient balances.
• Post Payments. Enter payment information into the practice management system and update the patient’s account.
• Adjust Account Balances. Apply necessary adjustments according to contracts and update any outstanding patient balances.

10. Follow-Up

• Denial Management. Examine the reasons for denied or underpaid claims and take steps for resubmission or appeal.
• Patient Billing. Send billing statements for any balances due and follow up on overdue accounts.
• Customer Service. Address any inquiries or concerns from patients or payers regarding billing or services rendered.

11. Reporting and Analysis

• Operational Reports. Generate reports detailing claim statuses, denials, payments, and accounts receivable to monitor financial health.
• Performance Analysis. Assess the efficiency of coding, billing, and collection processes to find areas for improvement.
• Compliance Audits. Conduct constant internal audits to verify adherence to billing and coding regulations.