Medical Billing and Coding in Wyoming

Our Medical Billing and Coding Process in Wyoming

1. Confirm Patient’s Insurance is Valid

• Verification Process. Before the patient receives care, the medical office staff confirms insurance coverage. This involves checking the patient’s insurance card and contacting the insurance provider to verify the policy number, coverage type, co-payments, deductibles, benefits, and other limitations.
• Pre-authorization. The insurance company may need pre-authorization for certain procedures or specialist consultations. This step guarantees that the insurance provider approves the coverage of the service.

2. Schedule an Appointment With the Provider

• Appointment Booking. The patient is scheduled for an appointment through scheduling software or via phone. During booking, staff confirms demographics, contact information, and insurance policy details.
• Reminders. Automatic reminders via phone or email are often sent to ensure the patient remembers the appointment.

3. Delivery of Care

• Consultation & Treatment. On the day of the appointment, the patient receives the care or treatment from the healthcare provider. This may include consultations, diagnostic tests, procedures, and follow-up recommendations.
• Documentation. Providers document all aspects of patient care, including diagnosis, treatment plans, prescriptions, and any advice given.

4. Details are Updated on the EMR (Electronic Medical Records)

• Data Entry. Post-treatment, details from the appointment are entered into the EMR system. This record includes patient history, diagnostic results, treatment given, and any recommendations.
• Accuracy Check. Ensuring the data entered is accurate and complete is critical, as this information is used for subsequent billing and coding processes.

5. Practice Support Identifies the Codes

• Coding Process. Our practice support staff or medical coders review patient records and identify the correct ICD-10 (International Classification of Diseases) codes for diagnoses and CPT (Current Procedural Terminology) codes for medical procedures performed.
• Compliance. Accurate coding is needed to comply with insurance company requirements and to ensure the practice receives appropriate reimbursement.

6. Delivery of Care (Second Occurrence)

• Additional Services. If patient care involves multiple visits or continued treatment, delivering care and updating the EMR is repeated as necessary.
• Ongoing Documentation. Continuous documentation is maintained to ensure that every additional service is recorded.

7. Claim Submission

• Claim Creation. Based on the coded procedures and diagnoses, we create a claim. This includes service details, patient information, and insurance information.
• Electronic Submission. Claims are typically sent electronically to the insurance company using standardized formats (e.g., HIPAA 837 format). Some practices may also submit paper claims.
• Timely Filing. Ensuring claims are submitted within the time frame to avoid denials due to late submissions.

8. Claim Processing

• Insurance Review. The insurance company reviews the submitted claim to determine if the services provided are covered under the patient’s policy.
• Adjudication. This includes checking eligibility, verifying coverage, and assessing co-payments, deductibles, or co-insurance amounts. The insurer may approve, deny, or request more information.

9. Payment Posting

• EOB/EOP. Explanation of Benefits (EOB) or Explanation of Payments (EOP) is received from the insurance company outlining what has been covered and any payment adjustments.
• Posting Payments. Payments received from insurance companies and patients (for co-pays or out-of-pocket expenses) are posted to the patient’s account in the billing system.
• Balance Billing. If any amount is not covered by insurance, the balance is billed to the patient.

10. Follow-Up

• Denial Management. If a claim is denied or underpaid, billing staff reviews the reason for denial. They may need to correct and resubmit claims or appeal the decision.
• Patient Follow-Up. Contacting patients for any outstanding payments or clarifying billing concerns.

11. Report and Analysis

• Reporting. Regular reports are generated to monitor the practice’s financial performance. This includes accounts receivable aging reports, denial rates, payment turn-around times, and revenue cycle metrics.
• Data Analysis. Analyzing data identifies trends, billing errors, and areas for improvement. It assists in enhancing operational efficiency and ensuring compliance with healthcare regulations.