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Unlocking the Mysteries of Medical Billing


When an unpaid medical bill is mysteriously rejected by the insurance company, Sherlock Doc is on the case!

Sherlock Doc knows that medical billing is the process a healthcare provider goes through to submit and follow up on a medical claim with an insurance company.

Medical billing is performed by medical billers, who may or may not hold special certifications from taking the CMRS Exam, RHIA Exam, or from attending medical billing school.

After a doctor sees a patient, various procedure codes and diagnosis codes are assigned to that patient based on their medical status.

These codes help the insurance company determine how much of the claim they will pay.

The medical biller submits the claim to the insurance company electronically.

Medical claims adjustors or medical claims examiners then review the claim and approve, reject or deny it based on patient eligibility and medical necessity.

The amount paid out to the healthcare provider is based on pre-agreed terms between them and the insurance company.

A claim is ‘denied’ when it has been processed and the insurer has determined it to be not payable. The medical biller may then appeal the claim for reconsideration.

A claim can be “declined” is there are any errors or inconsistencies in the submitted claim. For example incorrect procedure codes or misspelling of a patient’s name.

In this case, the medical biller must correct and resubmit the original claim.

To learn more about medical billing, insurance, coding, outsourcing, and everything you need to establish a successful healthcare practice, follow all of Sherlock Doc’s adventures on the DoctorsBusinessNetwork.com or Doctors Business Channel on YouTube!

Author: DBN

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