Medical Billing and Coding in Tennessee

Understanding Our Medical Billing and Coding Process

1. Confirming Patient Insurance Validity

• Verification. Gather complete insurance details from patients, including photos of both sides of their insurance card and any other required information.
• Eligibility Check. Confirm the active status and coverage of the insurance plan through phone calls or online platforms.
• Benefits Verification. Understand the plan’s specifics, such as co-payments, co-insurance, deductibles, and any required pre-authorizations or referrals.
• Document Results. Record all verification information in the patient’s records for future reference.

2. Scheduling Appointments With Providers

• Patient Information. Verify or collect the patient’s demographic data and medical history.
• Appointment Booking. Use the practice management system to schedule appointments based on the provider’s calendar.
• Reminders. Reduce no-show rates by sending phone, email, or text reminders.

3. Delivering Initial Care

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

4. Updating the EMR

• EMR Entry. Input visit details into the Electronic Medical Records system, including medical history, diagnostics, and procedure notes.
• Code Assignment Preparation. Ensure detailed and precise documentation to facilitate accurate coding.

5. Identifying Codes With Practice Support

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

6. Continuing Care (If Needed)

• Follow-Up Appointments. Schedule necessary follow-ups to maintain care continuity.
• Continuation of Care. Document follow-up visits thoroughly to record all services.

7. Submitting Claims

• Claim Preparation. Consolidate patient and service details for the claims process.
• Claim Validation. Use claim scrubber tools to detect and correct potential errors before submission.
• Electronic Submission. Submit claims via electronic data interchange (EDI) or a clearinghouse.
• Submission Confirmation. Document confirmation upon claim submission.

8. Processing Claims

• Payer Review. Insurance payers review claims for accuracy and eligibility.
• Determination. Payers decide whether to approve, partially deny, or reject claims.
• Explanation of Benefits (EOB). Log the EOB to document payer decisions regarding claims.

9. Posting Payments

• Receive Payment. Collect payments from the insurance payer and patients for any due balances.
• Post Payments. Enter payment details into the practice management system and update patient accounts.
• Adjust Account Balances. Apply necessary adjustments according to agreements and manage remaining patient balances.

10. Follow-Up Actions

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

11. Reporting and Analysis

• Operational Reports. To monitor financial health, generate detailed reports on claim statuses, denials, payments, and accounts receivable.
• Performance Analysis. Evaluate the efficiency of coding, billing, and collection processes to identify areas for improvement.
• Compliance Audits. Conduct regular internal audits to adhere to billing and coding regulations.