Medical Billing and Coding in Ohio

Learn Our Medical Billing and Coding Process in Ohio

1. Confirming Patient Insurance Validity

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

2. Scheduling an Appointment

• Patient Information. Confirm or collect the patient’s demographic information and medical history.
• Appointment Booking. Schedule the appointment using the practice management system according to the provider’s availability.
• Reminders. Send reminders via phone, email, or text to minimize no-shows.

3. Care Delivery (Initial Visit)

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

4. Updating the EMR

• EMR Entry. Enter visit details into the Electronic Medical Records system, including medical history, diagnostics, and procedure notes.
• Code Assignment Preparation. Conduct accurate and detailed documentation to support correct coding.

5. Identifying 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 provided services and comply with payer guidelines.

6. Follow-Up Care (If Necessary)

• Follow-Up Appointments. Schedule any required follow-up visits to maintain continuity of care.
• Continuation of Care. Thoroughly document follow-up visits to ensure all services are recorded.

7. Claim Submission

• Claim Preparation. Compile detailed patient and service data for claim processing.
• Claim Validation. Use claim scrubber tools to identify and correct potential errors before submission.
• Electronic Submission. Submit the claim via electronic data interchange (EDI) or through a clearinghouse.
• Submission Confirmation. Log the confirmation receipt upon claim submission.

8. Claim Processing

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

9. Payment Posting

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

10. Follow-Up

• Denial Management. Investigate reasons for denied or underpaid claims and take steps to resubmit or appeal.
• Patient Billing. Send statements for outstanding balances and follow up on overdue accounts.
• Customer Service. Address patient or payer inquiries regarding billing or services provided.

11. Reporting and Analysis

• Operational Reports. Generate reports detailing claim statuses, denials, payments, and accounts receivable to monitor financial health.
• Performance Analysis. Evaluate the efficiency of coding, billing, and collection processes to identify potential improvements.
• Compliance Audits. Conduct regular internal audits to verify compliance with billing and coding regulations.