Medical Billing: It Usually Starts Before The Actual Appointment

by  Find-A-Code™
May 11th, 2023

Unless you work as a medical coder or biller, you are probably unfamiliar with how the whole medical billing system works. There is a lot to it – from diagnostic codes to HIPAA compliance to turning a physician's notes into billable codes. Did you know that the billing process actually starts before you show up for your appointment?

Paying for healthcare is a convoluted process. At least it is if you have health insurance. If you pay cash for your healthcare, the process is pretty simple. You show up with cash, a check, or a credit/debit card. But when health insurance is involved, the process is anything but simple.

You Make the Appointment

It all starts when you contact your doctor's office to make an appointment. Or maybe you are going to see a specialist for the first time. Whether it is a clinical visit or a medical test, you get the ball rolling by making an appointment.

These days, in the era of electronic health records, healthcare providers often send electronic forms to patients prior to their visits. Patients are expected to complete the forms and send them back as soon as they can. Why? Because providers use the information to prepare for the visit.

Your Visit Is Pre-Authorized

Paying for care through health insurance might involve getting your insurance carrier involved early on. To avoid any confusion, healthcare providers sometimes take the step of contacting your insurance carrier to pre-authorize your visit and the services you are expected to receive. That way, you can be informed ahead of time of any possibility that your insurance will not cover your visit.

Along with pre-authorization, your healthcare provider will determine any copays or other fees you must pay at the time of service. You may or may not be informed of these amounts prior to your visit. In most cases though, you will be.

Just in these two steps alone, your healthcare provider has already started the medical billing process. Medical codes have been considered. The insurance carrier has been contacted. Your records have been updated to reflect why you are coming to see the doctor along with the services the doctor is expected to provide.

You Complete the Visit

When you arrive at the provider's office, you might be asked for additional information needed for billing purposes. At the very least, office staff will confirm your address, contact information, and insurance carrier. They want up-to-date information so that claims they make following your visit are not rejected. While you are waiting in the patient area to be called for your visit, the medical billing process continues in the back office.

You finally get in to see the doctor. Throughout the visit, your doctor takes notes that may or may not include actual medical codes. Regardless, your doctor's notes will be given to a medical coder at some point. It is the medical coder's responsibility to translate them into billable medical codes that eventually get forwarded to the billing department.

The Bill Is Prepared

Finally, a medical biller takes the information supplied by the coder and creates a bill that will be submitted to your insurance carrier for payment. Assuming everything goes off without a hitch, your insurance carrier will pay for all or part of the services you received. Any balance due might be billed to you in a separate statement.

Now you know the basic process that constitutes medical billing. It is not so simple. In fact, it begins before your actual visit. The moment you contact a provider to make an appointment, the medical billing process is set in motion.