1. Patient Registration: When a patient visits a healthcare provider (e.g., doctor’s office, hospital, clinic), they provide their personal and insurance information. This information is used to create a patient record and initiate the billing process.
2. Coding: Medical coders review the patient’s medical record and assign specific alphanumeric codes to each diagnosis, procedure, and treatment provided during the visit. These codes are essential for proper billing and are typically based on a standardized system, such as the Current Procedural Terminology (CPT) and the International Classification of Diseases (ICD) coding systems.
3. Claim Generation: Using the coded information, a medical biller creates a claim, which is a request for payment to be sent to the patient’s insurance company. The claim includes details about the services provided, the associated codes, and the costs.
4. Claim Submission: The completed claim is submitted electronically or through paper to the patient’s insurance company or payer. This step is critical as it initiates the reimbursement process.
5. Adjudication: The insurance company reviews the claim and determines the appropriate amount to reimburse based on the patient’s insurance coverage, deductibles, co-pays, and other factors. This process is known as claim adjudication.
6. Payment: Once the claim is adjudicated, the insurance company sends payment to the healthcare provider for the covered services. If there are any remaining costs that the patient is responsible for (e.g., co-insurance, deductible), the provider may bill the patient directly.
7. Denials and Appeals: In some cases, claims may be denied due to various reasons, such as coding errors, lack of pre-authorization, or coverage issues. When this happens, the provider may need to appeal the decision or correct any errors and resubmit the claim.
8. Patient Billing: If the patient has any financial responsibility, such as co-pays, co-insurance, or services not covered by insurance, the healthcare provider will bill the patient accordingly.

Medical billing is a complex and constantly evolving process, subject to regulations, rules, and guidelines set forth by federal and state agencies, as well as insurance companies. It requires skilled professionals with knowledge of medical coding, billing procedures, and insurance policies to ensure accurate and timely reimbursement for healthcare services.

Keep in mind that the specifics of medical billing can vary between different healthcare settings, specialties, and insurance plans. Additionally, healthcare providers often use specialized medical billing software to streamline the process and reduce errors.