Medical Billing & Transcription Process
July 5, 2008
In this blog I will try to explore how typical medical BPO companies process the medical bills from their offshore locations. Though this blog will not get into the details of the medical billing and transcription process, readers can understand how a typical medical billing and transcription company conducts their operation remotely.
Medical Billing & Transcription Process
Typically following are the steps involved in the day-to-day medical billing and transcription operations:
1. Medical BPO companies receive medical bills in various formats like those that scanned documents, electronic feeds, fax documents, audio files etc. Sometimes medical BPO professionals log into their customer’s computer remotely enter the bills into billing software and extract the data into their computer.
2. Offshore medical professionals analyze the data to make sure it has all the necessary information like Patient Name, SSN, correct billing code, etc. Sometimes they may get documents (transcribed files, discharge summary, triage sheet, etc.) that describe a procedure that is performed to a patient. In this case they identify following items:
i. Steps taken by the physician to perform the procedure to the patient
ii. Number of hours worked by the Physician
iii. Medications used in performing the procedure
Based on findings the medical coding professionals will identify the correct billing codes for each item to submit to billing clearing house.
3. Once all the data is identified, medical coding professionals will validate the integrity of the data against payer’s profile. Any missed information will be corrected at this stage by communicating it with the hospitals.
4. All the verified data is submitted to either billing clearinghouse or to the insurance company to be paid to the hospitals.
5. If either clearinghouse or insurance companies reject the claims for more details BPO professionals will research, identify, and fix the missing data to send it back to the billing clearinghouse for proper payments to the hospitals.
Medical Claims Verification Process
Following is the process medical billing and transcription companies go through in verifying the billing and transcription data from their customers:
Even though medical coding and billing standards exist, there are significant differences in the processes carried out by the hospitals, insurances, and billing clearinghouses. Hospitals send medical bills that vary considerably, same medical procedure are billed differently from hospital to hospital. In addition, both the data and interpretation of the data vary from hospital to hospital. Medical BPO companies process the medical data, identify all the inconsistencies in the data and store it in a Medical data Repository for various hospitals. BPO companies with very deep domain expertise in medical procedures will use custom-built Medical Rules Engine that goes through medical data repository to identify and fix the data inconsistencies automatically. If the rules engine software could not fix the data, it will report to the operator and the operator will fix the data manually. Companies with less domain expertise will use manual procedure to identify and fix the data inconsistencies by communicating with their customers.
When the BPO companies submit the bills, clearinghouse pays more than 75% of them without any issues. Remaining 25% are rejected due to various reasons like incorrect patient’s demographic information, incorrect diagnostic data, etc. In these situations, BPO companies work with their customers to resubmit the rejected claims. The medical data repository and the medical rules engine are constantly updated with new and accurate information based on the rejected claims.
Transmission of Medical Bills
Different hospitals will have different billing submission procedures. Some hospitals will use a single entity like clearinghouse and some other hospitals will directly submit their claims to the insurance companies like Blue Cross, Cigna, etc. Experienced medical BPO companies will use software to generate the appropriate files based on their customer needs to transmit them to appropriate entities. Some medical BPO companies will use manual process to create the files to transmit them to appropriate entities. Generally, the claim files are transmitted using NSF 3.01 or UB-92 formats.
The strength of medical BPO companies lies in their software and other related technologies they use in automating the steps in processing the claims. Experienced medical BPO companies use very little manual intervention in receiving, processing and sending the medical claims to either clearinghouse or to insurance companies.
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Medical transcript providers hold on to severe processes to make sure 100 percent accuracy in their service release. The medical transcription processes have been upgraded based on HIPAA regulations to stay away from risks connected with poor transcription quality. In current times medical centers and hospitals in many places like U.S. and UK have taken to medical transcription outsourcing as a cost efficient solution.
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