When a doctor sees a patient, how does that doctor’s office know exactly what to bill? How does that doctor get paid? If a service or procedure that was provided is denied, how does that doctor’s office know what to do to get that patient’s insurance company to pay?
To answer these questions, and to have an understanding of how a doctor is paid for each service provided to a patient, you have to know the whole process. Handling the Medical Claim: An 8-Step Guide on “How To” Correct and Resolve Claim Issues explains, from beginning to end, how a service provided in a physician’s office is billed and how reimbursement is collected.
To understand the process, I will begin with some basic good practice management skills. Every office must learn how to delegate specific job duties. Depending on the size of the doctor’s office or clinic, your duties may be divided up by job description or departments. In a large group clinic, different departments may be set up as follows: front office (includes patient data entry and appointments), medical records, transcription, triage/nurses station, administrative, and billing departments. The front office consists of appointments and patient data entry. The billing department includes a receipt poster (who enters the payment), charge entry and coders (who capture all the charges), and a billing representative, collector, or billing clerk (who researches and resolves claim issues). The credentialing officer maintains insurance contracts as well as licenses and certifications for all the providers in the clinic.