Medical billing is the process of submitting and following up on insurance claims with health care providers. It's a complex system that involves many steps, and it can be difficult to understand without some background knowledge. This article will provide an overview of the medical billing process, from start to finish.

Revenue Cycle Management (RCM) is a term used in the healthcare industry to describe all of the activities and processes that are associated with generating revenue from providing healthcare services. The RCM process begins when a patient receives treatment or care and ends when the provider is paid for that care.

The heart of the RCM process is the medical billing system, which is responsible for submitting and following up on insurance claims. In order for providers to receive payment from an insurance company, they must have a working medical billing system.

The process of receiving care from a healthcare provider begins long before the patient ever steps foot in the office. In order for a patient to receive treatment, he or she needs to be referred by a primary care physician, most likely one affiliated with the provider's network. Since most providers contract with several insurance companies, patients are often referred to the provider by their primary care physician's office according to the patient's coverage under that particular company.

The billing process can be difficult to understand for those who are not familiar with it. In order to claim insurance, patients must provide their insurance information to the healthcare provider. This information is used to submit a claim to the insurance company.

The insurance company then pays the healthcare provider based on the terms of the patient's policy. Most providers contract with several insurance companies, so it is important for patients to know which company they are covered by.

Some patients are required to pay a co-payment at the time of service, while others may have to wait until their claim is processed before receiving a bill.

Most healthcare providers use electronic medical billing (EMB), which allows them to submit follow-up on claims electronically. Most insurance companies also offer online access to claims information, which can allow providers to follow up with any issues immediately.

Data Collection For Billing System

Actual image of a Medical Billing Module. Requires a lot of manual inputs and a large administrative staff to manage.

There are three types of data that are typically collected for the preparation of a billing system: demographic data, insurance data, and treatment data.

Demographic data includes basic information about the patient, such as name, address, and Social Security number. This information is used to track the patient's account and to submit claims to the insurance company.

Insurance data includes information about the patient's insurance policy, such as the type of policy and the deductible amount. This information is used to determine how much the provider will be reimbursed for providing treatment to the patient.

Treatment data includes information about the services provided to the patient, such as the date of service, the procedure code, and the diagnostic code. This information is used to prepare the claim to submit to the insurance company.

●  Patient Data

Patient data is the information about the patient. It includes their name, address, birth date, gender, and insurance information.

●  Insurance Data

Insurance data has to do with the insurance that the patient has. This makes up who pays for what, when they are supposed to pay, and how much they pay.

●  Bill Modifications

The bill can be modified by adding services or procedures that were not originally billed for in order to get reimbursement for more of the treatment.

●  Claim Submissions

After the data has been collected it is time to submit the claims to the insurance company so they can reimburse the patient, or the provider if there is no coinsurance or deductible required. This needs to be done in a timely manner, as stated by state insurance laws.

●  Medical Data

The patient's injury or illness is typically designed by the physician. The physician will select the appropriate procedure code and diagnostic code to indicate what treatment was provided.

The diagnosis (or reason for visit) is also typically selected by the physician. This is used to determine the severity of the injury or illness and to assign a level of complexity to the claim.

Most providers use electronic medical billing (EMB), which allows them to submit follow-up on claims electronically. Most insurance companies also offer online access to claims information, which can allow providers to follow up with any issues immediately.

●  Services Rendered/Charge Data

Services rendered have to do with what was provided to the patient. This includes all of the procedures, tests, and assessments done by medical staff during treatment.

Charges can be a list of different values for a single service or procedure. Each line item on a statement is considered a separate charge. Charges are multiplied by the amount allowed by the insurance company.

Charges are a list of different values for a single service or procedure, with each line item being considered a separate charge. Charges are multiplied by the amount allowed by the insurance company to create a total charge.

Insurance companies handle billing in their own way, which can vary from one to another. However, they generally send out statements to patients at certain intervals summarizing the services they have received, the amount the patient owes, and the insurance reimbursement.

  • The claim processing system is used for gathering all of the information needed to submit claims to an insurance company.
  • The collected data will then be put into forms that are specific for each type of insurance company.
  • The data is then transmitted electronically to the insurance company for reimbursement.
  • After processing, the claims will be sent electronically or mailed to the type of insurance the patient has. The insurance company will either reimburse the patient or send a statement about what needs to be paid before they can process it as having been paid in full.
  • After this, the insurance company will then send a check to the provider or reimburse the patient for their portion. The patient will receive a statement about what is left if they have any amount still owed.

Medical Billing Vs Medical Coding

Medical Coding requires deep clinical understanding to ensure the diagnosis codes align with the services provided.

Medical billing and coding are two important aspects of the healthcare industry that work together to ensure patients receive the care they need and providers are compensated for their services. Medical billing is the process of submitting and following up on claims with insurance companies in order to be reimbursed for the services provided to patients. Medical coding, on the other hand, is the process of assigning procedure and diagnostic codes to medical services and treatments so that information can be tracked and reported.

Both medical billing and coding are important aspects of the healthcare industry that play a vital role in ensuring patients receive the care they need. Medical billing is the process in which claims are submitted to insurance companies in order to be reimbursed for patient care, while medical coding provides a numerical translation of the procedures provided during treatment.

Here's a great article that explains a little more about medical billing and coding.

In order for patients to receive coverage, providers must learn both billing and coding protocols in order to properly submit claims and follow up on any issues with reimbursement status.

At Enter, we believe that there should always be a separation of medical billing and medical coding. The coding team is highly clinical and should be working directly with providers to ensure they are accurately coding each service performed. Whereas, Billing is responsible for submitting claims but more importantly, finding trends in insurance claim adjudication and providing feedback to the coding team to then inform providers. 

How Medical Billing Software Works?

The main feature of medical billing software is the validation of each claim and coding before sending it. This helps to ensure that all of the information is correct before it's sent to the insurance company. This also helps to avoid any delays with reimbursement.

Medical billing software should also include a patient's eligibility and insurance plan status. This will help to ensure that the software is correctly submitting claims and that the patient is being billed correctly.

RCM In Medical Billing System

In addition to gathering records and submitting the insurance plan to payers, it is the accountability of the Medical Biller to make sure that the information is correct. Sometimes even a certification of medical billing is needed. This means double-checking the codes and making sure that all of the information is correct before sending it off. This also helps to avoid any delays with reimbursement.

Medical billing software should also include a patient's eligibility and insurance plan status. This will help to ensure that the software is correctly submitting claims and that the patient is being billed correctly. 

Revenue Cycle Management Process Flow

Click here for a detailed RCM flowchart

●  Insurance Eligibility Verification

The revenue cycle management process begins with the insurance eligibility verification. This is the process in which the insurance company verifies that the patient is covered under their plan. If they are not, then the claim will not be processed.

●  Patient Demographics

The patient's demographics include their name, date of birth, social security number, and insurance information. This information is used to determine the patient's eligibility for coverage and to submit the claim to the insurance company.

●  Medical Record

Medical records are needed for the coding. A medical biller gets the patient's name, date of birth, social security number, and insurance information.

These are used to make sure that a patient is qualified to be billed and qualifies for coverage.

A medical biller needs to know the medical record for each patient because it will tell them what codes to give a patient.

●  Coded Documents

Once medical coding is completed, the coded documents are sent to the charging entry department. This is the department that will process the claim and submit it to the insurance company. The charging entry department will also ensure that the patient is being billed correctly and that all of the information is correct.

Medical coders have to have a solid knowledge of anatomy and physiology to ensure that the codes are accurate. They also need good math skills in order to code surgical procedures correctly. Coders also need computer skills, experience working with medical billing software, and an understanding of insurance companies' guidelines.

The procedure and diagnosis codes that are assigned to a patient's care depend upon the type of treatment that is being administered. Coders need to know diagnostic and coding guidelines for medical billing in order to assign these codes. Diagnoses must be specific enough so that it is clear what condition the patient has been diagnosed with, yet general enough so that the insurance company will recognize the healthcare data

●  Electronic/Paper

Enter's automated medical billing platform generates electronic and paper claims automatically.


Providers or patients can submit a claim to the Payer. More professional and sophisticated provider groups will request an Assignment of Benefits from their patients and perform all RCM duties themselves. When providers submit a claim to their insurance company, they often want to know what happened to it. Did the insurance company reject it? Did it go through? Was it approved?

There are a few ways that providers (or patients) can track the status of their claim submission. One is to call the insurance company and ask for information. They may be able to tell you whether or not the claim was received and whether or not it was processed. This process is massively painful and requires about 20 minutes per claim of waiting on hold. 

Another way to track the status of your claim is by using your insurance company's website. Many insurance companies have a section on their website where you can enter your information and see the status of your claim submission. This will tell you whether or not the claim was received, processed, and approved. This process requires a lot of human labor and will take about 2-5 minutes per claim. 

Another way is by directly integrating with the Payer via EDI standard 276 which allows providers or their Revenue Cycle Management company, like Enter, to automatically poll the insurance carrier for a claim status. This process happens instantly and frees up time for your staff. 

●  Payment Posting

The payment posting and reconciliation system is in place to ensure that the payments received by the medical facility are matched with the claims submitted . This helps to avoid any discrepancies with payments and helps to keep track of the payments that have been made.

Once a Payment has been Posted, your billing and accounting team then work together to do Payment Reconcilable which is the process of matching each claim payment with each bank entry. 

●  Follow Up And Denial Management

The follow-up and denial management system is in place to ensure that the payments received by the medical facility from the insurance carrier are corrected based on the claims submitted. This helps to avoid any discrepancies with payments and helps to keep track of the payments that have been made. If there are any discrepancies, it will help to identify them and correct them. The follow-up and denial management system also helps to ensure that patients are being billed correctly and that all of the information is correct.

This process can be very tricky because, more often than not, Insurance Carriers will pay less than the charge amount. Having a system that is able to track and interpret denial codes from insurance is paramount to understanding payments. 

Enter's automated system analyzes payer denials and automatically follows up on underpayments and denials.

Additionally, following up with Payers is even more tricky. Most insurance carriers require a very detailed appeal or claim reconsideration. These appeals and reconsiderations typically must be faxed or mailed to the correct mailbox or fax number and must contain a cover letter, payer-specific appeal form, the CMS 1500 (in color), the explanation of benefits (EOB) and any supporting documentation for the claim, like patient history and medical records. 

●  Customized Reports

The final, and possibly most important, procedure in the revenue cycle management process is to provide customized reporting to the providers and administration. At a bare minimum, reporting must be shared on a monthly basis. At Enter, providers get a real time business intelligence suite along with monthly static financial reports.

Reports will include information such as the amount that has been billed, the amount that has been paid, and the amount that is still owed. It will also include information about the services that have been provided and the insurance company that was billed. Reporting should also have monthly aging reports by payers that shows how much each payer owes to the practice.

Click the link below for an in depth article on the process of healthcare billing

Qualities Of Medical Billing System

The medical billing system is in place to ensure that patients are being billed correctly and that all of the information is correct. It is also in place to ensure that the payments received by the medical facility are matched with the invoices generated. This helps to avoid any discrepancies with payments and helps to keep track of the payments that have been made.

It is important to have a strong knowledge of medical billing software, there are many types that differ depending on size and specialty. Understanding the different options can help medical billing companies pick out one that fits your needs.

Below we will discuss what exact qualities you should be looking for in your medical billing software.

●  EHR Interoperability

The most important quality of a good medical billing software infrastructure is to ensure that it integrates seamlessly and interoperates with your EHR system. This process can be very challenging and requires significant expertise by the Billing Software provider. If the billing software is not integrated into the EHR properly, it can create massive issues for your bottom line while creating a huge headache for your organization. 

●  Remote Accessibility

In today’s remote world, prior to selecting a medical billing software, you should first assess if the software is cloud based and has the security protocols to enable your billing team to work from home. IIf you want your employees to have access to information on the internet and do their work from home, you should look for a medical billing company that is cloud based and has strong security and HIPAA compliance.

●  Ability To Customize

The next quality you should be looking for is the ability to customize. In today's world, it has become increasingly important to have a medical billing system that is capable of adapting to your needs. The days where one company can produce a complete and full-featured product that is good for everyone are over.

You should be looking for a medical billing system that gives you the capability to customize it by allowing you to add your own fields, create custom fields and apply custom validation rules. By doing so, it will become easier for you or your employees to input information correctly thus further increasing accuracy in the healthcare facility.

●  Analytical And Problem-Solving Skills

Another important quality is the ability to provide analytical and problem-solving skills. It's true that many of these tasks can be automated but you need a medical billing system that is able to analyze your data and find issues on its own. Instead of having you or even worse your employees try to figure out what went wrong when something goes wrong, it would be better to let the system figure out the problem.

●  Experience And Training

When choosing medical billing software, one of the most important qualities to consider is experience. Not only does the company need experience in creating medical billing systems but also with customizing and implementing it within your organization. The other kind of experience you should be looking for is the training offered by the company. This will help your employees to learn about the medical billing system and get familiar with it even the coding services.  

One of the great things about the current state of technology is that there are so many different options out there for you to choose from. You should be looking for the system that offers the best value for your money without sacrificing quality. With access to information provided by articles such as this one and thorough research on the company you are interested in, it should be simple to select a medical billing software that will meet your needs.

●  Integrity

Integrity is one of the most important qualities that you should be looking for when selecting a medical billing software. It's worth noting that there are many companies out there that may seem great on the outside but are actually scams. What you need to understand is that no matter how reputable or popular they are, none of these companies can survive without customers. If you do your research, talk to former customers, and use common sense, you should be able to find out if it is a legitimate company or not.

●  Strong Organizational Skills

The last one of the qualities that you should be looking for in medical billing software is strong organizational skills. It's true that many of these tasks can be automated but it takes a lot more to actually create a great product. Your employees will have to use this product on a daily basis and the best thing you can do is purchase software that they can work with.

Benefits Of Medical Billing Services

The last thing you want is to implement an inefficient system that will only cause issues with your accounting department, create inefficiency and ultimately ruin your practice.

In order to avoid these common pitfalls, it's important that you do your research and choose a medical billing software that fits the bill. In this sense, choosing a quality product will be much more beneficial in the long run. It will save you time and money, eliminate errors, reduce the number of complaints from your customers, and increase accuracy.

The benefits of implementing good medical billing software within your organization are numerous. Here are some of the most important benefits you should be aware of:

●  Decreased Costs

One of the great things about having a medical billing system is that it can help to automate many processes. This will allow you to have increased accuracy, better compliance with HIPAA regulations, decreased costs, and increased productivity.

●  Reduced Paperwork And Rework

When you are collecting payment from individuals or insurance providers, it's important that everything is processed accurately. The last thing you want to do is process claims incorrectly or lose documentation because this will result in lost revenue. This is the reason why you should consider implementing a medical billing system that will reduce the number of errors you have to deal with.

●  Increased Compliance

In order to remain compliant, it's important that you do everything in your power to create an efficient claims process. This means creating barcodes for insurance providers, maintaining audit trails for HIPAA compliance, and eliminating potential risks. When you are able to do this, you should have access to the necessary documentation in the event of an audit.

●  Improved Productivity

When your medical billing software is well designed and structured it will allow your employees to complete their work much faster. This means that they can actually spend time on value-added services rather than waste time on mundane tasks that have little to no value when it comes to your customers.

●  Higher Profits

In the end, good medical billing software will not only increase revenue but it'll also help you remain profitable. This is because you can expect higher reimbursements and better compliance with regulations.

Final Thoughts

If you’ve ever wondered about the medical billing process, this article should help to clear up any confusion with an overview of all the steps. It can be challenging at times to understand how it works without some prior knowledge or experience in healthcare administration, but hopefully now that we've gone through each step together you'll have a better understanding. For more information on our best-in-class RCM solution for your practice, check out Enter.Health today!



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