Medical Billing: An In-Depth Look at Its Purpose, Process and Impact

From ensuring financial stability and transparency to acting as a link between providers, insurers, and patients, medical billing forms the cornerstone for quality care in the healthcare industry.

Yet, as Becker’s medical review found, approximately 80% of US medical bills contain inaccuracies. This not only disrupts cash flow but also undermines patient trust and satisfaction.

Thus, to help you understand the crucial aspects of medical billing and make well-informed decisions, we have brought up this piece of writing that delves deeply into the role, process, and impact of medical billing practices in the reimbursement cycle.

Let’s begin.

The 4 ‘W’ and 1 ‘H’ of Medical Billing

Most of us are familiar with the 5W1H concept, introduced by Rudyard Kipling, to extract the most accurate and relevant answer to any existing question. Drawing inspiration from this timeless formula, we have examined the fundamentals of medical billing through the lens of 4 ‘W’ and 1 ‘H’.

The 4 ‘W’ and 1 ‘H’ of Medical Billing

Understanding the core principles of medical billing not only helps healthcare entities eliminate errors, simplify workflows, and improve cash flow but also motivates them to embrace technology and patient-centric billing approaches.

For instance, studying what medical billing is can help practitioners maintain accuracy in documentation and evaluate the administrative workload. Similarly, getting a gist of when medical billing encounters challenges enables them to implement checks and measures that improve financial health and efficiency.

Additionally, obtaining a comprehensive view of what factors contributed to the medical billing evolution entrusts institutions to stay abreast of the market demands, healthcare regulations, and medical advancements.

So, let’s start with the very first one.

What Is Medical Billing?

In the US healthcare system, medical billing refers to the procedure of obtaining payments from the insurance companies for the care provided.

That means once the patient receives treatment, the provider submits a claim to the insurance company. This claim includes information on the type of diagnosis, therapy plans, and medication administered. The insurance company then reviews the claim based on the coverage and reimburses the amount directly to the provider or the patient.

Though this definition of medical billing sounds straightforward, the implementation becomes quite intricate due to the involvement of various steps, components, and stakeholders, each adding its own layer of intricacy. Such as:

  • The first step is to collect all the patient’s information, including their age, medical history, and health insurance details.
  • Then, verify the information with the insurance company.
  • Next is to document all the services rendered, including recurring appointments, diagnoses, treatments, and medications.
  • Following, translate procedures into standardized codes.
  • Thereafter, submit the claim.
  • Finally, monitor the claim process, make required adjustments, and follow up until the claim is approved and paid.

We will chart a way forward by stating the most viable solutions. But first, let’s analyse its root cause.

When Does It Encounter Challenges?

To identify and mitigate the complexities involved, it is essential to know about the root cause of the challenges. Precisely pinpointing the key triggers can help anticipate and eliminate obstacles.

Below are some of the most common areas prone to experiencing issues.

Coding Errors

According to WorldMetrics, coding errors can lead to an average loss of $1,200 per claim. The primary reasons include:

  • Insufficient or lack of detailed patient information, such as demographics, age, medical history, symptoms, recurring appointments, etc.
  • Wrong codes assigned to the rendered services
  • Lack of information on the ICD coding system
  • Misinterpretation of medical terminology
Solutions
  • Conduct comprehensive training for coders, physicians, and other staff members on accurate documentation procedures.
  • Run coded bills through multiple quality check layers
  • Invest in the latest technology like EHR Software and medical coding software

Claim Denials

In a survey by Experian Health, nearly 3 out of 4 providers said that the number of denied claims increased between 2022 and 2024. The central reasons are:

  • Errors in medical coding
  • Lack of pre-authorization
  • Submitting duplicate claims
  • Absence of medical necessity of the rendered services
Solutions
  • Establish Standard Operating Procedures (SOPs) for medical documentation
  • Stay updated with the payer policies and guidelines
  • Ensure effective communication between providers, physicians, coders, and other staff members
  • Conduct regular audits and identify claim denial patterns to find solutions for the recurring issues

Impacts On Revenue Cycle Management (RCM) For Cardiology

Transitioning to VBC models brings both opportunities and challenges for Cardiology practices, particularly in the area of revenue cycle management. Practices need to adapt their billing processes to account for bundled payments, quality-based reimbursements, and the complexities of managing risk-sharing agreements. This requires sophisticated RCM systems that can handle performance-based payments, track quality metrics, and ensure compliance with the latest regulations.

Some key RCM adjustments for cardiology practices include:

  • Tracking quality metrics: Ensuring that clinical outcomes and patient satisfaction are properly documented to receive full compensation.
  • Managing bundled payments: Efficiently billing for entire episodes of care, from diagnosis to post-discharge follow-up, without missing out on revenue.
  • Navigating risk-sharing arrangements: Understanding the financial risks and rewards associated with value-based contracts.

Claim Rejections

Unlike claim denials, claim rejections happen even before the claim enters the processing ecosystem. It occurs at the clearinghouse. While a rejected claim can be resubmitted after rectifying the issue, a denied claim cannot be paid. As per an editorial published in Healthcare Finance, providers are seeing a rise in claim rejections as high as 10 to 15%. The leading reasons include:

  • Incorrect patient data and missing information
  • Non-adherence to policy terms and conditions
  • Mistaken diagnostic or procedural codes
  • Claims filed after the allowed period
  • Outdated insurance details
Solution
  • Provide thorough medical records
  • Submit claims within the required time frame
  • Maintain accuracy in diagnostic and procedural coding
  • Conduct regular audits to identify and address issues
  • Keep stakeholders updated with insurance guidelines

Overlooking Compliance

As per one of the recent posts in the HIPAA Journal, in 2021, 37.5 million records were exposed in 64,180 data breaches. The main causes behind these complications include:

  • Lack of healthcare regulation and standards awareness
  • Absence of role-based training on compliance
  • Miscommunication between provider and administrative staff
  • Not prioritizing and allocating enough resources to regulations and compliance
Solutions
  • Forming a dedicated team to look after compliance activities
  • Investing in compliance management software
  • Promoting a culture that prioritizes compliance
  • Double-checking documents and conducting regular audits

However, in the past few years, medical billing has evolved to be more digital, drastically shifting from traditional paper-based methods. Several factors have channeled these transitions; we have discussed the most significant ones in the subsequent section.  

Which Factors Have Contributed To Its Evolution?

Which Factors Have Contributed To Its Evolution?

From the appearance of Electronic Health Records (EHRs) and computer-assisted coding (CAC) to the advancement of machine learning and GenAI, medical billing systems have transformed to be more transparent, accurate, efficient, and secure.

Here’s what compelled this evolution.

A Rise In Patient-Centric Care

With the wide acceptance that patients should be active participants in their own healthcare rather than passive recipients of the provider’s treatment, healthcare entities have adopted a more patient-centric and value-based approach. Moreover, with the recent World Health Day 2024 theme, My Health My Right, there is a prominent recognition of a further evolution from ‘patient-centric’ to ‘human-centric’ care. This metamorphosis has opened doors to:

  • Clear, concise, and transparent billing practices.
  • Better communication between patients, providers, and insurance companies.
  • User-friendly patient portals and RCM systems.

Feedback mechanism, automated payment options, upfront cost estimates, and so on.

The Dynamic Nature Of Healthcare Regulations

The rules and regulations of the healthcare industry constantly evolve to address new challenges, embrace technological advancements, and respond effectively to dynamic patient-care standards. This necessitates the medical billing ecosystem to be robust, flexible, and capable of integrating the modifications, which in turn led to:

  • Utilization of software to manage and update policies in real-time.
  • Development of standardized protocols and programs that identify, assess, and mitigate compliance risks.
  • Popularity of regularity reporting tools and real-time data analytics.
  • Appointment of dedicated regulatory and compliance teams, comprehensive training, and so on.

Increased Focus On Data Security And Privacy

The healthcare industry holds plenty of sensitive information in the form of patient records. Some high-profile data breaches highlighted their vulnerabilities to misuse and unauthorized access. For instance, in 2011, Tricare Data Breach exposed the personal health data of 4.9 million patients. This underscored the pressing need to maintain the confidentiality and integrity of medical billing practices, which led to:

  • End-to-end encryption during data transmission or storage.
  • Implementation of multi-factor authentication and strict access controls.
  • Enactment of stringent cybersecurity and privacy protocols.
  • Regular security audits and adherence to healthcare regulations.

The Advent Of AI-Driven Solutions

Before AI, medical billing practices were labor-intensive and susceptible to human errors and inefficiency. The emergence of AI made the process faster and more accurate by automating monotonous tasks like data entry, coding, and claim processing. However, the impact of AI in the reimbursement cycle is not just limited to automation; a number of its ground-breaking contributions extend to:

  • Predictive analysis entitles institutions to well-informed and data-driven decision-making.
  • Fraud detection, protecting healthcare entities from financial losses.
  • Real-time processing of billing information, scalability, enhanced reporting, simplified workflows, and more.

How Are We Keeping You At The Forefront Of This Change?

Having served more than 600 clients globally, we are the pioneers of advanced billing solutions. Committed to round-the-clock service and keeping the milestone of 94000+ coded charts/month, you can rely on us for quicker payments, simplified processes, and reduced expenses.

This is achieved by enhancing automation, eliminating duplicate tasks, and promoting efficient workflows based on the industry’s best practices. Get in touch today to leverage the unique amalgamation of our team, methodologies, and tech-driven innovations alongside a steadfast dedication to the clientele we partner with.

Learn more here.

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