Introduction to Billing and Coding

The patient presents an appointment

Adrian is a patient having a back problem. He needs to get immediate help from a medical officer. The first step he needs to take is book for an appointment with the doctor before proceeding to meet him or her at the health centre. While at the health centre, Adrian must fills in the relevant forms to ascertain treatment. Considering he was a new patient, this form would be the patient information form in which he provides his bio-data consisting of demographics, personal particulars, and insurance verification data (entails full name, address, group name, illness codes, identification number, and social security number) to be sent to the billing office. If he was a returning patient, this would be a matter of updating the existing patient profile.  The fact that Adrian is covered by a medical insurance plan, he needs to give his approval by signing personally. “As part of the form or separately, the patient usually signs an assignment of benefits” (Newby, 2010). This gives authority for payments to be made to the doctor directly.

Provision of Medical Services to the affected Patient

Here Adrian will essentially undergo examination in order to properly ascertain his back condition. All observations are properly updated in the patient’s records. “Also stated are the diagnoses-the physician’s opinion of the nature of the patient’s illness or injury-and the procedures…” (Newby, 2010). The doctor fills in these details in his respective encounter form specifying in addition, the charges involved. “In order to perform insurance claims filling, the medical billing service must receive copies of the daily encounter forms from each medical office for which he or she does billing” (Farhat & Cummins, 2008).

The Patient’s Health Plan is Accurately Subjected to Billing

Adrian’s details in the encounter form are used to process the claim on the health plan. The medical charges for that day are included taking into account previous visits to the doctor, which have not been settled. The doctor then sorts the various claims into distinct batches according to the different insurance companies to which each claim is to be forwarded.  The doctor also needs to filter the claims according to service provided and the respective procedure codes followed. This process can alternatively be done electronically, which is essentially more common (Newby, 2010).

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The Patient’s Health Plan Issues a Response to the Presented Claim

The insurance company proceeds to examine the forwarded details for the patients covered under the plan. In Adrian’s case, this would entail confirming the fact the treatment issued and procedure implemented matches the back condition for which it was intended. If this is not the case payment to the claim will be denied. If the details are correct then this are deducted from the insurance claims fund. Adrian needs to potentially abide by the payment amounts required by the policy holder in order for this to be successful. The insurance company determines the amount of benefit then proceeds to issue an explanation of benefits, which is also known as the remittance advice (Newby, 2010). Payment forms may be made directly to the patient or indirectly to the policy holder.

The Patient gets billed accordingly

Once the explanation of benefits or remittance advice is received, Adrian’s details are once again proof checked. The exact amount indicated on the remittance advice is posted on the billing program (Newby, 2010). If Adrian had an alternative plan, say a second active health plan this is also included to cater for a deficit in case it occurs on the current plan. Supposing there was an additional payment to be made, this will be accordingly billed to Adrian.

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