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A Profile of The Business of Medical Billing

by Austin Mcmillian (2020-03-05)

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meMA9Wq.jpgKnowing the nuances of medical billing and medical billing company, the functionalities of the same and the changing importance down the industrial ages.

The concept of a medical billing company
In the United States of America, the medical industry functions in an unconventional way. When a patient and a doctor meet each other, the former furnishes an insurance code to the later which is in turn placed before the respective insurance company for verification. After the insurance policy is checked for the coverage clauses, the payment procedure begins, at the end of which the insurance company compensates the doctor financially for the medical goods delivered and services rendered to the patient. The process of compensation payment and its calculation is a complicated one which is either executed by the clerical staff of the medical service provider or by customized companies specializing in medical billing and revenue cycle management. In the former case the practice management loses money and accumulates back log due to lack of professionalism and in the later case the special firm recovers the revenue smoothly and posts the payment to the clients' account.

The reason justifying its existence
The legalities governing the rules of revenue recollection are complex and quick changing. That apart, the process of verification, clarification, analysis, coordination, denial contesting and finally recovering the due compensation from the payers and crediting the same to the client's account is a task which demands ultimate professionalism, client communication and trading tactics which are not easily mastered by a non-professional agency like a doctor's office. Earlier when customized medical billing was not in practice, medical firms used to take care of the billing requirements for themselves leading to

confusion, delays and deferred payments. Now-a-days institutionalized agencies perform all the formalities following the protocols and execute revenue management responsibilities smoothly. Hence the need to shift from manual labor to digitized duties.

The operation
The work process followed by most medical billing companies can be summarized as under.

Eligibility and authorization verification

Patient information entry


Charge entry

Claim submission

Payment Posting

Accounts receivable

Denial management

Medical Billing is a part of the total process of revenue cycle management which precisely means collecting the essential papers and calculating the exact amount of the financial worth of the service claim. Even that has a large number of steps associated with it which are as follows

Rx Order Entry

Patient demographics and insurance entry

Product code/ Rx and Dx entry

Eligibility verification and authorization

Collection of complete Rx

Collection of documents for auth approval


Rejection and denial management

A/R follow up
The evolution
Medical billing has gained immense popularity in the recent years which has led to graduate and post graduate syllabus include in revenue service management papers which forms an individual discipline in its own right. After passing out of such a professional course, which provides training in both theory as well as hands on practice, students get job in reputed medical billing companies in their preferred area of work. These companies employ digitalized practice management to serve their clients better with speed, accuracy and economies of scale.

This author is a renowned medical billing practice manager who has worked for the top medical billing companies and Prior authorization services in the states.

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