When it comes to medical billing, making sure workflow processes are in place can make a world of difference for your organization. Two processes come into play: front-end and back-end. Front-end processes are the start of a medical claim before it is sent to the patient’s insurance company and the back end is everything that needs to be done once the claim is submitted. Let’s get into a quick detailed overview of what these processes are.
As we stated in the introduction of this article, front-end processes start at the moment a patient makes their doctor’s appointment. This includes gathering all the patient’s information including name, address, phone number, date of birth, insurance name, policy number, and any other patient information or forms needed from the provider's office.
Once that information has been given, and all documents have been signed by the patient, staff members proceed by verifying the patient’s information and insurance coverage to determine if the patient’s insurance policy is active, what procedures the patient’s insurance covers, if referrals or prior authorizations are needed before services are rendered and if there is any patient responsibility beforehand. After this has been determined, staff members communicate the appropriate information to the patient.
The patient sees the provider and after the completion of the encounter and the patient leaves the provider's office, and the documentation and superbill of all the medical services that have been provided have been created into a claim is when the back-end billing starts.
At this point in the process, a medical biller takes the superbill and creates a claim that includes diagnosis codes, and CPT/procedure codes, with the appropriate amounts for each service, the provider's information along with the NPI is correct, and the correct place of service. The medical biller also ensures that the claim is compliant with the coding and formatting of the claim by reviewing billable codes and makes sure the claim follows all payer guidelines according to the patient’s insurance, and that HIPAA & OIG guidelines have been met.
The medical biller submits the claim electronically or by paper through the established clearinghouse or by mail with the correct claims mailing address for claims processing. It is now time to monitor the adjudication for the claim and follow up with the insurance for claim status as it relates to payment or denial of the medical claim.
Other items that are included in the back-end process of medical billing consist of payment posting payments from the patient's insurance company, appealing if necessary for any denial of the claim, or sending the patient a statement if the patient owes any outstanding amount based on their insurance guidelines and collect payment from the patient.