Editorials by Jorie

The medical billing process with a medical billing system.

he medical billing process may seem daunting, but it can be broken down into simple steps with the aid of a medical billing system.

These steps include: Registration, establishment of financial responsibility for the visit, patient check-in and check-out, checking for coding and billing compliance using a medical billing system, preparing and transmitting claims through the system, monitoring payer adjudication, generating patient statements or bills with the system, and assigning patient payments and arranging collections using the system.

It's important to note that there are "front-of-house" and "back-of-house" duties when it comes to medical billing, and a reliable medical billing system can help ensure that the entire process runs smoothly.


The process of registering patients for a doctor's visit can be simplified with the use of a medical billing system. When a patient calls to schedule an appointment, they effectively pre-register for their visit. For returning patients, their information is already on file in the medical billing system, so they only need to explain the reason for their visit. However, new patients must provide personal and insurance information to the system to ensure that they are eligible for the provider's services.

By utilizing a medical billing system, healthcare providers can streamline the registration process, ensure that patient information is recorded accurately, and reduce the risk of errors in the billing process. This system can help providers verify patient eligibility for insurance coverage and help patients understand their financial responsibility for the services they receive. Ultimately, using a medical billing system can save time and effort for both the provider and the patient.


Confirming financial responsibility for a doctor's visit is an essential step in the medical billing process, and a medical billing system can help simplify the task. Once the biller has collected the necessary information from the patient, they can use the system to determine which services are covered under the patient's insurance plan.

Insurance coverage can vary significantly between companies, individuals, and plans, making it crucial for the biller to check each patient's coverage to assign the bill correctly. Some insurance plans may not cover certain services or prescription medications, and the biller must use the medical billing system to verify insurance coverage. If the patient's insurance plan does not cover the procedure or service to be rendered, the biller must inform the patient that they will be responsible for the entirety of the bill.

By using a medical billing system, billers can quickly and accurately confirm a patient's financial responsibility, avoid billing errors, and ensure that services are billed correctly. The system can also help streamline the process of verifying insurance coverage, reducing the time and effort required by the biller.


Patient check-in and check-out are essential procedures that can be streamlined with the aid of a medical billing system. When a patient arrives, they will need to complete necessary forms or verify their information if they have visited the provider before. The patient will also be required to present official identification, such as a driver's license or passport, along with a valid insurance card.

Copayments are collected at the point of service during patient check-in or check-out, and it is up to the provider to decide whether the patient pays before or after their visit. A medical billing system can help automate the process of collecting copayments and ensure accurate recording of the patient's financial responsibility.

After the patient checks out, the medical report from the visit is sent to the medical coder for abstraction and translation into accurate, usable medical codes. This report, known as the "superbill," contains demographic information on the patient, their medical history, and all the necessary information about the medical services provided, including the name of the provider, physician, procedures performed, and diagnosis and procedure codes. The superbill is a critical component in the medical billing process, and its accuracy ensures timely and appropriate billing.

With the help of a medical billing system, patient check-in and check-out processes can be efficiently managed, from collecting copayments to ensuring the accuracy of the superbill. The system can also facilitate the establishment of financial responsibility for the patient's visit, checking for coding and billing compliance, and preparing and transmitting claims. A well-implemented medical billing system can help providers avoid common billing errors, reduce payment delays, and improve overall revenue cycle management.


It’s important to note that ensuring compliance is a critical step in the medical billing process. If a claim is found to be non-compliant, it can result in a denial of payment or even legal action against the provider.

In addition to compliance, billers must also ensure that the claim is transmitted to the payer in the proper format. This can include using a specific electronic data interchange (EDI) system, sending the claim via fax or mail, or using an online portal to submit the claim.

Once the claim is submitted, the biller must monitor the payer’s adjudication process. This involves tracking the status of the claim and ensuring that it is being processed in a timely manner. If the claim is denied or partially paid, the biller must follow up with the payer to determine the reason for the denial or partial payment and take appropriate action to correct the claim.

Overall, the process of preparing and submitting claims is a critical part of the medical billing process. It requires a high level of accuracy and attention to detail to ensure compliance and maximize reimbursement for both the provider and the patient.


HIPAA regulations mandate that health entities covered by HIPAA must submit their claims electronically, with few exceptions, since 1996. Most providers, clearinghouses, and payers fall under the scope of HIPAA.

However, it's worth noting that physicians are not obligated to conduct all transactions electronically under HIPAA. Only the transactions listed under HIPAA's standard guidelines must be electronically completed, with claims being one of them.

Manual claims are still an option for billers, but they have several disadvantages, such as a high error rate, low efficiency, and a lengthy transmission time from providers to payers. Billing electronically saves time, effort, and money while significantly minimizing human or administrative error in the billing process.

For high-volume third-party payers such as Medicare or Medicaid, billers can directly submit the claim to the payer. If the biller is not submitting a claim directly to these large payers, they will most likely go through a clearinghouse.


After receiving the report from the payer, the biller proceeds to generate the invoice for the patient. This invoice shows the amount due for the procedure(s) received by the patient from the provider. Once the payer has approved and paid the provider for a portion of the services on the claim, the outstanding amount is billed to the patient.

In some instances, an Explanation of Benefits (EOB) may be included with the invoice. An EOB outlines the benefits and coverage the patient receives under their insurance plan. EOBs can be helpful in clarifying to patients which procedures were covered by their insurance and which were not.

The final stage of the medical billing process involves ensuring that the bills are paid. This includes mailing accurate medical bills on time, and following up with patients who have delinquent bills. Once a bill has been paid, the biller stores the payment information with the patient's file.

If a patient's payment is delinquent or incomplete, it's the biller's responsibility to ensure that the provider is properly reimbursed for their services. This may involve contacting the patient directly, sending follow-up bills, or involving a collection agency in extreme cases.

Keep in mind that each provider has its own payment guidelines and schedules, as well as notification and collection policies. Therefore, before taking any of these actions, refer to the provider's billing standards.

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