The good news?

With the right Medicaid billing steps, it soon becomes routine.

Whether you run a solo office, work in a group practice, or just joined a Medicaid plan, you need a clear roadmap for the entire process.

This guide from BellMedEx gives you exactly that.

What Is Medicaid?

Medicaid is a health program jointly run by the federal and state governments in the U.S. It now covers more than 80 million people, including:

• Children
• Pregnant women
• People with disabilities
• Low-income adults
• Seniors who also receive Medicare (known as “dual eligibles”)

Why Should Healthcare Providers Treat Medicaid Patients?

Many providers worry that Medicaid pays less than private insurance or Medicare. Still, three major reasons make it worth considering:

Large patient pool – Medicaid covers a fast-growing segment of the population, especially in underserved areas.

State-level incentives – Some states offer extra perks like value-based payments or higher rates for specific specialties.

Community impact – You’re helping some of the most vulnerable people. That service brings lasting value to your community.

Here’s How to Bill Medicaid as a Provider:

Here’s a full breakdown of how to bill Medicaid successfully, from credentialing to getting reimbursed.

Step #1 – Enroll as a Medicaid Provider

You can’t send a single reimbursement claim to Medicaid until the program adds you to its roster. Therefore, your first job is getting on that list.

Think of it like joining the payroll before payday.

a). Find your state’s portal

Every state runs its own enrollment portal, and they all live on official .gov pages. A quick search for “[Your State] Medicaid provider enrollment” on Google will land you on the right link.

For example:

• In Texas, you’ll use TMHP (Texas Medicaid & Healthcare Partnership).
• In California, it’s PAVE (Provider Application and Validation for Enrollment).

If the web address doesn’t end in .gov or belong to a well-known state partner, then don’t trust it.

b). Collect the paperwork before you log in

Have these items ready before you start the Medicaid provider enrollment form:

c). Complete the online application

• Log in or create an account on your state’s portal.
• Follow each screen. Upload documents as asked.

If a field stumps you, most portals have a help line or live chat—so use it. You can also call the state’s Medicaid provider relations office, as that team’s entire job is guiding newbies like you through enrollment.

d). Let the state verify you

After you click Submit, the state reviews your file. This “Medicaid credentialing” step checks licenses and other data.

• Time frame is usually between 30 to 90 days.
• Faster for solo providers.
• Slower if you enroll a new group practice.

Once approved, you’re ready to send Medicaid claims and get paid as a healthcare provider.

Step #2 – Verify Patient Eligibility Before Each Visit

Eligibility verification simply means you confirm, ahead of time, that Medicaid still covers your patient and the service you plan to provide. A quick check spares you from most “patient not eligible” denials.

a). First, pick the method that fits your day:

• State Medicaid portal: Log in, type the patient’s Medicaid ID or birth date, and you get an instant “yes” or “no.”
• EHR or clearinghouse tool: Many systems ping Medicaid in real time. If coverage has lapsed, you’ll see a pop-up before the patient arrives.
• Medicaid helpline: A phone call takes longer, yet it helps when the portal is down or the data looks odd.

b). When you run the check, look for four things:

1. Confirm active coverage for today. Benefits can end quickly if a patient’s income changes or renewal paperwork is delayed.
2. Review service limits. Office visits are usually covered in most states, but extras—such as dental, vision, or chiropractic care—may have caps or require prior approval.
3. Check for a managed care plan. Many Medicaid members belong to an MCO. If you see “Molina,” “UnitedHealthcare Community Plan,” or another HMO name, send the bill to that plan—not directly to the state.
4. Look for other insurance. Third-party liability (TPL) means the patient has private insurance too. Medicaid pays last, so you must bill the other plan first, even if it only covers part of the charge.

Step #3 – Confirm That Medicaid Covers the Service

You have your Medicaid ID. You’ve checked the patient’s eligibility. One last check keeps your claim safe: make sure the service itself is on your state’s covered list.

When we say “make sure the service is on your state’s covered list,” we mean this: look up the exact CPT or HCPCS code for the visit, test, or procedure you plan to bill. If that code isn’t shown as covered in your state’s Medicaid fee schedule—or if it needs prior approval—you risk a denial.

Here’s how to see what Medicaid will pay?

a). Open your state’s fee schedule

Search for “Your State Medicaid fee schedule 2025.” Look for a PDF or spreadsheet on a .gov site.

b). Scan the CPT or HCPCS codes you plan to use

The schedule shows:

• Whether the code is covered
• The dollar amount Medicaid pays
• Any limits, such as age caps or visit counts
• Whether prior authorization is required

Example: North Carolina allows up to 30 physical therapy visits a year. Another state might allow only 15—or none, unless the patient is under 21.

c). Check plan bulletins for updates

States post monthly or quarterly alerts. A code that paid last year may need approval today.

d). Call the authorization desk when in doubt

A five-minute call beats a denied claim.

Step #4 – Secure Prior Authorization When It Counts

You have the patient’s Medicaid card on file, you know the service is on the covered list, and you’re ready to book the test.

Great…

but hold on a moment!

Some services need prior authorization (PA) before you provide them. Getting that green light is the difference between a paid claim and a painful write-off.

➜ Spot the usual PA suspects

As a rule of thumb, if a service is pricey, ongoing, or ordered by a specialist, plan on requesting a PA:

• High-cost imaging: MRI, CT, PET
• Elective surgeries: tonsillectomy, joint replacement, bariatric procedures
• Therapy past routine limits: mental-health counseling, speech, PT, OT
• Durable medical equipment (DME): power wheelchairs, hospital beds
• Ongoing home-health or skilled-nursing visits

Quick example:

Your patient with chronic knee pain clearly needs an MRI. You open the Medicaid HMO’s PA list and, sure enough, the scan needs approval. Rather than gamble on reimbursement, you pause, submit the request, and wait for the go-ahead.

➜ A simple roadmap for requesting PA

a). Choose the right portal

Every state—or Medicaid HMO—runs its own PA system. Some accept secure online forms; others still rely on fax. Therefore, you need to pick the path the healthcare payer prefers.

• Fill in the nuts and bolts
• CPT or HCPCS code for the service
• ICD-10 code that backs up the medical need
• Provider and facility info
• Target date of service

b). Attach proof of need

Your clinical notes, past imaging, lab results, or a referring specialist’s letter strengthen the request. Think of this bundle as answering the question, “Why does this patient need this service right now?”

c). Send, then track

Most plans give a decision within a few business days, sometimes sooner if you flag the case as urgent. Log the submission date and reference number so no one has to guess where the request stands.

d). After you hear back

• Approved. You’re free to schedule the service. Save the approval letter or confirmation number in the chart and billing file.
• Denied. Read the reason line by line. Many denials stem from missing paperwork or the wrong diagnosis code, both fixable on appeal.
• Need more info. Plans may ask for clearer notes or an extra test result. Provide what they need and resubmit; no need to start from scratch.

Step #5 – Submit Your Medicaid Claim

You have checked the patient’s coverage, confirmed the service is allowed, and grabbed any prior approval you need. Nice work. Now let’s make sure you actually get paid.

a). Pick the right claim form

• CMS-1500. Use this for office visits, shots, labs, or any other professional service.
• UB-04. Use this when you bill as a facility—hospital stays, outpatient surgery, skilled-nursing care.

Even if you hit “submit” inside your EHR, these forms sit behind the scenes. The software fills them in for you.

b). Drop in the correct codes

• ICD-10 tells Medicaid why you treated the patient.
• CPT or HCPCS show what you did.
• Modifiers add detail. For a flu shot given during a check-up, list:
  • 99213 – office visit
  • 90686 – flu vaccine
  • 90471 – vaccine administration
  • -25 on 99213 to prove the visit was separate from the shot.

c). Add a Place-of-Service (POS) code

This code shows where the care happened. A few you’ll use often:

• 11 – office
• 22 – outpatient hospital
• 12 – home
• 31 – skilled-nursing facility

Check this code twice. A wrong POS is a top reason claims bounce back.

d). List the right NPI numbers

• The rendering provider NPI must match the person who gave the care and must match the NPI on file with Medicaid.
• If you bill as a group, add the group NPI too.

e). Choose how to send the claim

• Through your EHR or practice management software. Fastest. The system fills the claim and flags missing data before you hit send.
• Through a clearinghouse. Acts like a mailroom: it scrubs errors, then routes the claim to the correct Medicaid payer.
• Direct upload to the state portal. Handy if you bill only now and then or do not have an EHR.

f). Track the claim afterward

Submitting is only half the job. Log back in a few days later and look at:

• Status – pending, paid, or denied
• Payment amount – matches your fee schedule?
• Remittance advice (RA) – explains reductions or denials

Catching a denial early often means a quick fix rather than a drawn-out appeal.

Step #6 – Track Each Claim and Match Every Dollar

Submitting the claim is only halftime. To get paid in full, you still need to watch the claim move through the system and confirm the deposit hits your account. A little follow-through here prevents big revenue leaks later.

a). How to keep eyes on your claims

➜ State Medicaid portal

Log in, search by patient or claim number, and read the status line: submitted, pending, paid, or denied.

➜ Clearinghouse dashboard

Tools like Availity or Office Ally show real-time updates—when Medicaid received the claim, whether it passed edits, and when it heads to payment.

➜ Remittance advice (RA) or EOB

This document tells you what was paid, reduced, or refused and why. Review it line by line as soon as it arrives.

b). Denials that pop up most

• Bad patient data – a wrong Medicaid ID or mistyped birth date can sink the claim.
• Coverage gap – the patient was not eligible on the service date.
• NPI or Tax ID mismatch – your claim info does not match Medicaid’s enrollment file.
• Missing prior authorization – the service needed approval, but no PA number was on the claim.

c). Reconciling payments the smart way

• Match every deposit to the specific claim in your billing system.
• Flag under-payments at once—was it a contract adjustment or an avoidable denial?
• If you need to appeal, move fast; many Medicaid programs close the window after 90 days.

Step #7 – Fix and Resubmit Denied or Rejected Claims

A denial is normal. It just means something on the claim needs a quick edit. Most states let you correct and resend—as long as you do it within their time limit (often 90–180 days from the date of service).

a). Read the denial note

Look at the Remittance Advice, EOB, or your portal. Find the short code that tells you what went wrong.

• CO-16 – missing or wrong info
• PR-49 – patient not eligible that day
• CO-96 – wrong code or modifier
• CO-109 – service not covered

b). Fix the problem

• Correct any typos in the patient name, Medicaid ID, or date of birth.
• Add the right modifier (-25, -59, etc.).
• Swap in the correct diagnosis or procedure code.
• Include the PA number if you left it off.

If the denial is about medical need, attach your notes or test results to show why the service was required.

c). Resend the claim

Use the same route you used before—portal, clearinghouse, or EHR. Mark it as a corrected claim if your state asks for that. Some states want the original claim number or a resubmission code (often “7” for a replacement claim).

d). Watch the deadline

Send the fix before the timely-filing window closes. If you are already past it, file an appeal right away and explain why you could not meet the deadline (for example, a system outage or mail delay).

e). Keep a simple denial log

Write down each denial in a list:

• Patient name and service date
• Denial reason
• Date you fixed it
• Date you resent it
• Final result

Seeing the patterns helps you prevent the same mistake next time.

The Medicare system can be daunting at first. However, once you master the enrollment process and billing requirements, you’ll find it manageable. This step-by-step guide helps you learn how to bill Medicare as a provider, from Medicare claim submission to getting paid.

Many new providers struggle with Medicare’s documentation requirements and coding standards. Others face delays because they miss enrollment deadlines or submit incomplete applications. Let us share practical steps to avoid these common pitfalls while maximizing your reimbursements.

How to Bill Medicare as a Provider (Complete Guide)

Medicare billing process for providers requires three essentials:

• Proper enrollment to Medicare
• Accurate claim submission
• And ongoing compliance.

To bill Medicare as a provider, you must obtain an NPI number and enroll through the Provider Enrollment, Chain, and Ownership System (PECOS). Next, you’ll verify patient eligibility and gather required documentation before submitting claims to your Medicare Administrative Contractor (MAC). Finally, you must maintain accurate records and update your enrollment information as needed.

The entire process follows a structured workflow designed to protect both providers and beneficiaries. Medicare uses standardized systems like the resource-based relative value scale (RBRVS) to determine payments. Your MAC processes claims and handles communications throughout the billing cycle. Success depends on understanding each step and following established guidelines consistently.

What is Medicare? And What Does Medicare Billing Mean for Providers?

Medicare serves as America’s federal health insurance program for adults aged 65 and older. The program also covers younger individuals with specific disabilities or permanent kidney failure. The Centers for Medicare and Medicaid Services (CMS) manages this vast system that processes billions of claims annually.

Medicare program divides into three main parts that affect your Medical billing strategy.

For providers, Medicare billing means following federal regulations while serving eligible beneficiaries. You must determine which Medicare part covers each service you provide. Some patients only qualify for certain coverage types, which affects your billing strategy.

Medicare may act as a secondary payer when patients have other insurance coverage.

Understanding Medicare’s structure helps you navigate billing requirements more effectively. Each part has different rules, payment schedules, and documentation needs. Your billing staff must recognize these differences to submit accurate claims and avoid denials.

How to Bill Medicare as a Provider (Step-by-Step)

Successfully billing Medicare requires following a systematic approach from enrollment through payment reconciliation. The process involves multiple steps that build upon each other to ensure compliance and maximize Medicare reimbursement.

Here are the nine essential steps every provider must master:

1. Obtain an NPI Number
2. Enroll in Medicare
3. Verify Enrollment and Maintain Compliance
4. Verify Patient Eligibility and Coverage 
5. Gather Required Documentation
6. Submit Claims to Medicare
7. Respond to MAC Communications and Track Claims
8. Receive Payment and Reconcile Accounts
9. Maintain Records and Compliance

Let us dive a little deeper into these steps to billing Medicare as a healthcare provider.

1. Obtain an NPI Number

Your National Provider Identifier (NPI) serves as your unique healthcare identifier across all transactions. This 10-digit number links all your Medicare billing activities to your practice or facility. Without an NPI, you cannot submit claims or receive payments from Medicare.

Apply for your NPI through the National Plan and Provider Enumeration System (NPPES) website. The application process requires basic information about your practice, including your name, address, and taxonomy code.

Note: Individual providers and healthcare organizations each need separate NPI numbers.

The NPPES system typically processes applications within 10 business days. You’ll receive your NPI via email once approved. Keep this number confidential and use it consistently across all Medicare transactions. Never share your NPI with unauthorized individuals or organizations.

Some providers already have NPI numbers from other insurance billing. You can use the same NPI for Medicare if it’s still active and accurate. Verify your existing NPI information through the NPPES registry before proceeding to Medicare enrollment.

2. Enroll in Medicare

Medicare enrollment establishes your eligibility to bill the program for covered services. The process varies depending on whether you’re an individual provider or institutional facility. Individual physicians typically complete the CMS-855I form, while groups use CMS-855B forms.

Access the enrollment system through PECOS, Medicare’s online platform for provider registration. Create your account using your NPI number and basic practice information. The system guides you through each section of the enrollment application.

Institutional providers face additional requirements during enrollment. Hospitals, skilled nursing facilities, and similar organizations must pay application fees. These fees vary by provider type and are updated annually on the PECOS website.

Prepare supporting documentation before starting your application. You’ll need copies of your professional license, malpractice insurance, and curriculum vitae. Some provider types require additional certifications or accreditations. Having these documents ready speeds up the enrollment process.

3. Verify Enrollment and Maintain Compliance

Your Medicare Administrative Contractor (MAC) reviews your enrollment application and may request additional information. Respond promptly to any MAC communications to avoid processing delays. The review process can take several weeks depending on your provider type and application completeness.

Once enrolled, you must keep your information current in the PECOS system. Report ownership changes, legal actions, or address updates within 30 days. Other enrollment changes must be reported within 90 days. Failure to maintain current information can result in payment delays or enrollment termination.

Institutional providers may undergo site visits or surveys during the enrollment process. Your CMS Location and State Agency coordinates these evaluations. Prepare your facility for inspection and ensure all required documentation is readily available.

Monitor your enrollment status regularly through PECOS. The system shows your current status and any pending actions. Address any issues immediately to maintain uninterrupted billing privileges. Set calendar reminders for important deadlines and renewal dates.

4. Verify Patient Eligibility and Coverage

Patient eligibility verification prevents claim denials and ensures proper billing. Check each patient’s Medicare status before providing services. Use your MAC’s portal or eligibility verification tools to confirm coverage details.

Determine whether Medicare serves as the primary or secondary payer for each patient. Other insurance coverage may take precedence over Medicare in certain situations. Workers’ compensation, employer group health plans, and auto insurance often pay before Medicare.

Collect comprehensive insurance information from every patient. Use the CMS Questionnaire or similar forms to gather employment and coverage details. Ask about spouse’s insurance, recent accidents, and work-related injuries. This information helps identify other potential payers.

Document your eligibility verification efforts in the patient’s record. Note the date, method, and results of your verification. This documentation supports your billing decisions and helps during audits or appeals. Update eligibility information if the patient’s circumstances change.

5. Gather Required Documentation

Accurate documentation forms the foundation of successful Medicare billing. Collect all necessary information before submitting claims to avoid delays or rejections. Your documentation must support the medical necessity of services provided.

Start with basic patient demographics including name, date of birth, and Medicare Beneficiary Identifier (MBI). Verify the patient’s address and contact information. Ensure the MBI matches exactly with Medicare’s records to prevent processing errors.

Select appropriate diagnosis codes using the current ICD-10 system. Choose codes that accurately reflect the patient’s condition and support the services provided. Use the most specific code available and include secondary diagnoses when relevant.

Identify correct procedure codes using CPT or HCPCS Level II codes. Match procedures to appropriate diagnosis codes to demonstrate medical necessity. Apply modifiers when required to clarify services or indicate special circumstances. Review coding guidelines regularly!

6. Submit Claims to Medicare

Electronic claim submission offers the fastest and most reliable method for Medicare billing. Use HIPAA-compliant systems that meet federal privacy requirements. Most practice management systems include Medicare billing capabilities.

Submit claims through your MAC using approved Electronic Data Interchange (EDI) formats. The standard format for professional claims is the 837P transaction. Institutional claims use the 837I format. Ensure your medical billing system supports these formats.

Paper claims serve as a backup option when electronic submission isn’t possible. Use the CMS-1500 form for professional services or the UB-04 form for institutional services. Complete all required fields and include supporting documentation when necessary.

Medicare Advantage patients require different claim submission procedures. Send these claims directly to the patient’s specific plan administrator, not to traditional Medicare. Each Medicare Advantage plan has its own submission requirements and contact information.

7. Respond to MAC Communications and Track Claims

Your MAC processes all Medicare claims and manages communications throughout the billing cycle. Monitor your submissions regularly and respond promptly to any requests for additional information. Delays in responding can result in claim denials.

Track claim status through your MAC’s provider portal or electronic systems. Claims typically process within 14-30 days depending on complexity. Follow up on any claims that exceed normal processing times.

Address claim rejections immediately by reviewing error messages and correcting problems. Common rejection reasons include invalid patient information, coding errors, or missing documentation. Resubmit corrected claims as soon as possible.

Appeal denied claims when you believe Medicare’s decision is incorrect. Submit additional documentation or clarification to support your position. Follow the appeals process outlined by your MAC and meet all required deadlines.

8. Receive Payment and Reconcile Accounts

Medicare payments arrive via electronic funds transfer to your designated bank account. Payment amounts reflect the Medicare fee schedule minus any applicable deductibles or coinsurance. Reconcile payments against your submitted claims to identify any discrepancies.

Review your Medicare Summary Notice (MSN) or Electronic Remittance Advice (ERA) for payment details. These documents explain what Medicare paid, what the patient owes, and any claim adjustments. Use this information to bill patients for their portion of costs.

Handle patient billing carefully to comply with Medicare regulations. You cannot bill patients for services that Medicare doesn’t cover unless you provide proper advance notice. Use Advance Beneficiary Notices (ABNs) when services may not be covered.

Track your accounts receivable to ensure timely payment collection. Follow up on unpaid claims and patient balances according to your practice’s policies. Maintain detailed records of all collection efforts for audit purposes.

Tip: Some visits can be billed incident-to and pay the full doctor rate even if a nurse practitioner saw the patient. Learn the rules here → [Medicare incident-to billing guide]

9. Maintain Records and Compliance

Medicare requires providers to maintain comprehensive records for audit and compliance purposes. Keep all billing documentation, patient records, and correspondence for at least five years. Some states have longer retention requirements.

Update your PECOS enrollment information whenever changes occur. Report new locations, ownership changes, or changes in services provided. Keep your contact information current to ensure you receive important Medicare communications.

Participate in Medicare audit requests promptly and thoroughly. Provide requested documentation within specified timeframes. Maintain organized records that allow quick retrieval of information during audits.

Stay informed about Medicare policy changes and updates. Subscribe to your MAC’s newsletters and attend provider education sessions. Changes in coverage, coding, or billing requirements can affect your reimbursement if not implemented properly.

Medicare Provider Billing Guidelines

Medicare billing guidelines are a set of rules that providers must follow when submitting claims for reimbursement. Following these guidelines helps providers submit claims accurately. This also protects healthcare providers and beneficiaries.

Key Medicare provider billing guidelines include:

• Document medical necessity for all services in patient records
• Use accurate CPT, HCPCS, and ICD-10 codes for all procedures and diagnoses
• Apply modifiers correctly to indicate service variations or special circumstances
• Submit claims within 12 months of service date
• Determine primary vs. secondary payer status for each patient
• Bundle services appropriately and avoid improper unbundling
• Accept Medicare’s approved amounts when participating in the program
• Maintain accurate patient insurance and employment information
• Coordinate benefits with other insurance carriers when applicable
• Respond promptly to MAC requests for additional information
• Keep detailed records for audit and compliance purposes
• Update enrollment information within required timeframes
• Follow appeals procedures for denied claims
• Bill patients appropriately for non-covered services with proper notices
• Use electronic submission methods when possible
• Protect patient information according to HIPAA requirements

Common Medicare Medical Billing Questions

Let us answer some of the most common Medicare billing questions for providers.

1. What is the Medicare billing process?

The Medicare billing process involves submitting claims electronically to your assigned Medicare Administrative Contractor (MAC) for covered services. You must first enroll in Medicare, obtain an NPI number, and verify patient eligibility before providing services.

After treatment, you code the services using appropriate CPT and ICD-10 codes and submit the claim within one year. Your MAC reviews the claim for accuracy and compliance with Medicare guidelines. They may request additional documentation or clarification before processing payment. Once approved, Medicare pays 80% of the approved amount for Part B services. Patients remain responsible for deductibles and coinsurance.

2. What providers can bill Medicare?

Medicare accepts claims from a wide range of healthcare providers including physicians, nurse practitioners, physician assistants, and clinical specialists. Hospitals, skilled nursing facilities, home health agencies, and hospice organizations also qualify for Medicare billing.

Other eligible providers include physical therapists, occupational therapists, speech-language pathologists, and clinical social workers.

Suppliers such as ambulance services, durable medical equipment companies, and independent diagnostic testing facilities can also bill Medicare. Healthcare providers must enroll in the Medicare program and meet requirements established by CMS. Enrollment requirements vary by provider type and may include licensing, accreditation, or certification standards.

3. Is provider based billing only for Medicare?

Provider-based billing extends beyond Medicare to include Medicaid and some Medicare Advantage plans. This billing method separates professional and facility charges for services provided in hospital-based outpatient clinics or departments. CMS requires this approach for government programs. But some insurance companies also use provider-based billing models.

The requirement affects facilities that have relationships with hospitals and bills under the hospital’s NPI number. Private insurance plans may combine professional and facility charges into single bills, but Medicare and Medicaid maintain separate billing requirements.

4. Are providers required to bill Medicare?

Most providers must submit claims to Medicare for covered services provided to Medicare beneficiaries, regardless of their participation status. Participating providers agree to accept Medicare’s approved amounts and must file claims for all covered services. Non-participating providers can accept assignments on a case-by-case basis but must still submit claims.

Providers can opt out of Medicare entirely by entering into private contracts with patients. In this arrangement, providers cannot bill Medicare and patients pay entirely out-of-pocket. Certain exceptions exist for small providers, roster billing, and demonstration projects. But the general rule requires claim submission for covered services.

5. How to Bill Medicare Electronically?

Electronic Medicare billing uses HIPAA-compliant systems to submit claims through Electronic Data Interchange (EDI) transactions. Providers transmit claims to their MAC using direct data entry screens or practice management software. The system automatically checks claims for errors and returns rejected submissions for correction before final processing.

Most healthcare facilities use clearinghouses or billing services that handle electronic transmission. These intermediaries convert claims into proper EDI formats and manage the submission process. Electronic billing reduces processing time, minimizes errors, and provides faster payment compared to paper submissions.

6. What Payment Will I Receive From Medicare?

Medicare payments follow the resource-based relative value scale (RBRVS) system that calculates reimbursement based on resources required for specific services. Payment amounts vary by geographic location, provider specialty, and service complexity. The Medicare Physician Fee Schedule provides specific payment rates updated annually.

Medicare pays 80% of approved amounts for Part B services, with patients responsible for remaining costs. Part A payments vary by service type and may include deductibles or coinsurance. Providers who accept assignments agree to Medicare’s approved amounts as full payment. Non-participating providers can charge limited additional amounts above Medicare’s rates.

This can happen for many reasons. You might miss some patient information. A code might be wrong. Or no one followed up with the payer. No matter the cause, delayed claims create problems. They hurt your cash flow, frustrate your patients, and add stress to your team.

Here’s the good news: most delinquent medical claims are easy to prevent. With the right systems and a few simple habits, you can keep your billing on track.

In this blog, you’ll learn how to avoid claim delays, get paid faster, and keep your practice running smoothly.

What Is a “Delinquent” Claim?

Before we talk about prevention, it’s important to understand what a delinquent claim actually is.

A delinquent claim is a health insurance claim that hasn’t been paid by the insurance payer to the healthcare provider within the expected timeframe. For most payers:

• Electronic claims are expected to be paid within 30 days
• Paper claims usually have up to 45 days

These timelines apply across most commercial insurers, as well as Medicare and Medicaid.

To meet these deadlines, healthcare providers must move quickly and accurately—from patient registration, through coding, to final claim submission. But if anything in this process is missed or delayed, the claim may not get paid on time.

If a payer doesn’t send payment within their expected window, the claim becomes delinquent. At this point, either the provider’s in-house billing staff or their outsourced medical billing company must take action. This could involve:

• Reviewing the claim for missing modifiers or CPT/ICD-10 coding errors
• Confirming the claim was received by the payer or clearinghouse
• Resubmitting the claim, if necessary

It’s important to note: a delinquent claim is not the same as a denied claim. The claim may still be “processing,” placed “on hold,” or delayed due to something as simple as an incorrect payer address or a missing document.

When a Claim Becomes Delinquent?

A claim becomes delinquent when it:

• Is at risk of being denied, written off, or sent to collections
• Has been unpaid beyond 30 days (for electronic claims) or 45 days (for paper claims), depending on the payer
• May be held up due to missing information, errors, or payer issues

Impact of Delinquent Claims

When a claim drags past its due date, three parties feel the impact — your medical practice, the payer, and the patient. Here’s the clear, step‑by‑step chain of events.

Stage 1 – Claim Sits in A/R (Day 0 – 30)

	Details
Trigger — Why it happens	Claim is submitted but pends or denies for data, coding, or eligibility errors.
What your team does	Biller edits the claim, rebills, and calls the payer for status.
What actually happens	Cash that should arrive in 14 days now sits in Accounts Receivable (A/R).
Who feels it	Practice leadership — KPIs such as “days in A/R” climb, squeezing cash flow.

Stage 2 – Patient Becomes the Payer (Day 31 – 60)

	Details
Trigger — Why it happens	Payer downcodes or denies the service. Your policy shifts the balance to “patient responsibility.”
What the patient sees	A surprise bill (e.g., $300) appears in the mailbox or portal.
What actually happens	Confused patients delay payment, waiting for “another insurance adjustment.” After 60 days a $25 late fee applies.
Who feels it	Patient – shock and frustration. Practice – still no cash, clerical load rises.

Stage 3 – Collections Take Over (Day 61 – 120)

	Details
Trigger — Why it happens	Patient ignored at least two statements and a final notice. Your financial policy—signed at intake—sends ≥ 60‑day accounts to collections.
What the agency does	Calls or texts the patient up to three times a week; adds a 15–20 % fee (e.g., $325 → ≈ $390); offers payment plans.
Who feels it	Patient – stress grows with every call. Practice – online reviews blame your clinic, not the agency, eroding trust.

Stage 4 – Credit Report Damage (Day 180 +)

	Details
Trigger — Why it happens	Unpaid balance > $500 remains in collections for 180 days. Agency reports it to Experian, Equifax, and TransUnion.
What actually happens	Credit score may drop 50–100 points.
Who feels it	Patient – faces higher loan rates and may skip follow‑ups. Practice – loses revenue from missed care.

Stage 5 – Lawsuit & Public Record (Month 6 – 18)

	Details
Trigger — Why it happens	Large balances (often >$2,000) remain unpaid; hospitals or debt buyers sue in states like New York, Texas, or California.
What the court does	Adds filing fees, attorney costs, and may approve wage garnishment. Case becomes public record.
Who feels it	Patient – faces legal risk and long‑term credit damage. Practice – name appears in court documents, signaling harsh collections—even if the root cause was a preventable claim error.

How to Prevent Delinquent Medical Claims?

Delinquent medical claims aren’t just an inconvenience — they directly threaten your revenue flow.

When claims aren’t paid on time, it creates a domino effect of rework, patient confusion, lost revenue, and wasted hours chasing down answers.

The good news? Most of it’s preventable.

Here’s how healthcare practices can prevent claims from going delinquent, improve cash flow, and reduce stress.

1). Get It Right at the Front Desk

The front desk may not stamp invoices, yet it controls every data element a payer will judge. One mistyped policy number or an expired plan on file can trigger a denial that costs weeks of rework.

• Verify insurance at every visit. Run a real‑time eligibility (RTE) check before the patient sits down.
• Scan IDs and cards. Store both sides in the EHR for instant reference.
• Confirm spelling aloud. Catch name or date‑of‑birth errors while the patient can still correct them.

2). Scrub Every Claim Before Submission

Claim scrubbing is a second set of eyes—only faster. By auto‑flagging code mismatches in seconds, you stop denials before they enter the payer’s system.

• Pass every encounter through a clearinghouse. Let software spot CPT/ICD‑10 conflicts, missing modifiers, and NPI errors.
• Fix alerts on the spot. Aim for a 97 percent or better clean‑claim rate.

3). Monitor Submitted Claims Actively

A claim can disappear into a payer queue, gathering dust while the filing clock keeps ticking. Real‑time monitoring surfaces silent claims early, so you can nudge them before they stall out.

• Set status alerts. Flag any claim that shows no movement after 14 days.
• Run daily aging reports. Assign each silent claim to a staff owner for follow‑up.

4). Follow Up Early — Not After It’s Too Late

Denials aren’t death sentences; they’re calls to action. A tight, seven‑day appeal cycle converts many of them into full reimbursements—long before they qualify as delinquent.

• Route denials by reason code. Coding, medical necessity, eligibility, and prior auth each get a separate queue.
• Appeal within seven calendar days. Include corrected codes, notes, and supporting records in one packet.

5). Patient Financial Engagement

Patients pay faster when they know exactly what they owe and have friction‑free ways to settle up. Transparent, tech‑friendly billing keeps their balances from aging into collections.

• Send e‑statements the day a balance posts and follow up with a text reminder.
• Offer no‑interest payment plans for balances over $200.
• Publish estimates and financial‑assistance options online and at check‑in.

6). Create a Denial Management Workflow

Denied claims are the biggest gateway to delinquency—unless you treat them with factory‑grade precision. A clear playbook turns firefighting into an orderly, repeatable process.

• Categorize denials (coding error, prior auth, eligibility, medical necessity).
• Prioritize high‑dollar, appealable claims.
• Rework and resubmit within five to seven days.
• Track root causes so one fix can eliminate dozens of future denials.

7). Use a Centralized Claims Dashboard

Spreadsheets hide patterns; dashboards reveal them. A single, color‑coded view of every claim lets your team tackle the oldest and riskiest accounts first—before they slip past timely‑filing limits.

• Show total outstanding claims with aging buckets (0–30, 30–60, 60–90, 90+).
• Highlight payer bottlenecks and denials awaiting action in real time.

8). Keep the Whole Team Informed

Your coders, clinicians, and front‑desk staff all leave fingerprints on a claim. Regular knowledge‑sharing keeps small mistakes from snowballing into systemic cash delays.

• Hold a monthly revenue‑cycle huddle. Bring front desk, coders, billers, and providers together.
• Share payer rule changes and new denial trends.
• Coach clinicians on documentation gaps that trigger “medical necessity” denials.

9). Automate Where You Can

Manual keystrokes breed errors and burnout. Automating routine tasks frees your staff to focus on higher‑value work like appeals and patient calls.

• Automate eligibility checks, claims submission, denial alerts, aging reports, and balance reminders.
• Integrate RCM and EHR systems to eliminate double entry.

10). Build a Claims Quality Checklist

A simple checklist is a tiny time investment that prevents month‑long payment delays. Think of it as your claim’s boarding pass—no errors, no hold‑ups.

• Insurance verified
• CPT and ICD‑10 codes match
• Modifiers and prior‑auth included
• Claim passed scrubber
• Correct payer ID

11). Don’t Miss Timely Filing Deadlines

Payers don’t negotiate filing deadlines. Miss one and the revenue is gone—appeals included. Rigorous deadline tracking keeps every claim alive until it pays.

• Catalog each payer’s limits (e.g., 90 days, 180 days).
• Flag claims 30 days before expiration for urgent follow‑up.
• Apply the same countdown to denials; resubmit well before cutoff.

Conclusion

Take last month’s aging report, grab a marker, and swipe every claim older than 30 days. Jot a quick note beside each one (missing code, no authorization, wrong ID) whatever tripped it. When the same problem shows up twice, that’s your fix for the week. Give it five days; if the payer still hasn’t moved, get a live rep on the phone. Do this every week and slow‑pay surprises lose their punch before they drain your cash or your team’s patience.

While write-offs can sometimes be an agreed-upon reduction, they can also lead to bad debt and significant revenue loss if not managed correctly. This article breaks down what write-offs are, how they differ from adjustments, when to write off a claim, and how to avoid unapproved or unnecessary write-offs.

One quick thing; we know that effective provider write-offs and precise claim management are important. That’s why, we help you manage them with our expert medical billing RCM specialists. Get free consultation with us to learn how.

What is Provider Write Off in Medical Billing?

A provider write-off in medical billing is the portion of a billed charge that a healthcare provider decides not to collect, either from the patient or insurance company. It occurs when a provider is unable to collect the full amount for a service rendered, usually due to agreements with insurance companies, legal requirements, or internal policies.

Write-offs are important for maintaining accurate financial records and ensuring compliance with various contractual or regulatory standards. Instead of continuing to pursue payment for these uncollectible amounts, providers “write them off” as unpayable.

For example, if a healthcare provider charges $700 for a procedure, but the insurance company’s contract stipulates a payment of only $500, the $200 difference is written off as a contractual adjustment. This is a common form of write-off that happens in healthcare. Another example could be when a patient’s balance is too small to justify collection efforts.

Major Types of Provider Write Offs

Here are some examples of provider’s write offs:

• Contractual Write-Offs
• Bad Debt Write-Offs
• Charity Care Write-Offs
• Small Balance Write-Offs
• No Insurance Write-Offs
• Promotional Write-Offs
• Timely Filing Write-Offs
• Uncredentialed Write-Offs

➜ Approved or Necessary Write-Offs

These write-offs are unavoidable and are part of the financial policies or contractual agreements between the provider and the payer.

Contractual Write-Offs

Contractual write-offs are necessary when a healthcare provider agrees to accept a lower payment from an insurance company than what was billed. This write-off is due to the allowable fee set by the payer, as per the terms of the contract.

For example, if a provider bills $1,000 for a service but the insurer’s contract allows only $700, the $300 difference is written off.

Charity Write-Offs

Charity write-offs are offered when a provider forgives a portion or the entire bill for patients who cannot afford to pay. This usually occurs when the patient qualifies for a financial assistance program due to their low income. These write-offs reflect the provider’s commitment to serving the community.

Small Balance Write-Offs

Small balance write-offs occur when the outstanding amount is too small to justify the administrative effort of billing or collection. For example, if a patient owes $12, the provider may choose to write off the balance rather than spending time and resources to collect it.

These write-offs are commonly seen when the amount is under $15 or $20, and the provider may add it to a future visit or simply let it go.

Promotional Write-Offs

Promotional write-offs are offered to encourage patients to pay in full at the time of service. This is common for self-pay patients who do not have insurance. For example, if patients paying out of pocket agree to pay in full during their visit, doctors might offer a discount or reduce the bill.

➜ Unnecessary Write-Offs

Unnecessary write-offs are avoidable and occur due to errors or inefficiencies in the billing process and are avoidable.

Timely Filing Write-Offs

Timely filing write-offs occur when claims are submitted after the payer’s deadline. Each insurer has specific filing timeframes, such as Medicare requiring claims to be filed within 12 months. If your practice misses these deadlines, you may have to write off the charges.

To avoid this, track claim submission deadlines carefully and set reminders to ensure timely filings for each payer.

Uncredentialed Provider Write-Offs

Uncredentialed provider write-offs happen when claims are filed for a provider who isn’t yet credentialed with the insurance company. This results in a denial of the claim and a write-off of the amount.

To avoid this, always verify the provider’s credentialing status with the payer before providing services. If needed, inform patients about non-covered services or self-pay options in advance.

Administrative Write-Offs

Administrative write-offs are granted when mistakes occur in the practice, such as when a provider mistakenly tells a patient that they are in-network with their insurance, but they are not. These situations may result in the practice writing off the charges as a courtesy.

To minimize these errors, ensure your team is well-trained on insurance verification and communicate clearly with patients about in-network and out-of-network status.

Collection Agency Write-Offs

Collection agency write-offs occur when unpaid balances are transferred to a third-party agency. These amounts are no longer pursued by the provider but are instead handled by the collection agency. However, they should not be forgotten entirely.

Monitor accounts with unpaid balances and only schedule new appointments after patients agree to a payment plan.

Bad Debt Write-Offs

Bad debt write-offs occur when a provider chooses not to pursue payment from a patient or insurance company due to unsuccessful collection efforts. This usually happens after several attempts to collect payments have failed.

To reduce bad debt, ensure your practice follows up on outstanding balances, verifies insurance coverage before services are rendered, and offers payment plans when necessary.

How to Avoid Unnecessary Write Offs

Avoiding unnecessary write-offs can significantly improve your practice’s bottom line.

Here are effective strategies to minimize revenue loss.

1. Use Reporting and Analytics Tools

Take advantage of medical billing software with built-in analytics. These tools can spot trends and areas where you’re losing money, allowing you to act before write-offs happen.

2. Conduct Regular Audits

Perform internal audits to identify any recurring issues, such as incorrect coding or billing mistakes. By catching these errors early, you can avoid unnecessary write-offs.

3. Train Your Staff

Ongoing training for your billing and coding team is essential. Ensure they understand the latest industry regulations and know the correct procedures to follow. Well-trained staff make fewer errors, which reduces write-offs.

4. Stay Compliant

To prevent denials and bad debts, make sure to follow all payer requirements, including insurance verification, pre-authorizations, and timely claims submission. Compliance with these rules is key to avoiding unnecessary write-offs.

Can Doctors Write Off Unpaid Bills?

Yes, doctors can write off unpaid bills, but the process and reasons behind it vary based on the situation and the policies of the medical practice. There are several scenarios where write-offs may be appropriate, for example, bad debt, charity care, small balance, etc.

But you must take care of these points, when writing off unpaid bills:

• Ensure that write-offs are well-documented and compliant with internal policies.
• Constantly monitor unpaid bills and analyze patterns to minimize future write-offs.
• Adhere to IRS guidelines for bad debt deductions while maintaining efficient billing practices to minimize unnecessary write-offs.

Can a Provider Write Off a Deductible?

Providers cannot write off deductibles because these amounts are parts of the patient’s financial responsibility. Writing off deductibles, copayments, or coinsurance can violate insurance contracts and may lead to contract termination, HIPAA violations, or even charges of fraud. It can also run afoul of the federal Anti-Kickback Statute (AKS), which is a felony.

But there are limited exceptions where providers might waive fees, such as in hardship cases or charity care. Even so, the decision to lower or remove a copay or deductible must be made for each case separately and cannot be done regularly.

Always, consult with an attorney or a billing specialist like BellMedEx to understand the specific rules and regulations that apply to your situation. Speak to our medical billing specialist now.

When Can You Write Off Medical Bills?

You can write off medical bills on your taxes if they exceed 7.5% of your adjusted gross income (AGI) and you itemize your deductions on Schedule A (Form 1040). This includes payments for diagnosis, treatment, prevention, and other medical care expenses that aren’t reimbursed by insurance.

🛈 How to Properly Write Off Medical Bills as a Provider?

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Let us share quick, actionable steps on how to rightly write off as a provider.

1. Identify Eligible Write-offs

• Review the claim to determine if it qualifies for a write-off.
• Look for reasons like insurance denials, patient financial hardship, or billing errors.
• Assess if the bill is uncollectible due to coverage limits or patient circumstances.

2. Document the Reasoning

• Keep detailed records of why you are writing off the bill.
• Note if it’s due to a payer’s denial, a patient’s inability to pay, or a contract issue.
• Ensure you document any supporting evidence like financial hardship applications or denial letters.

3. Follow Internal Policies

• Establish clear guidelines for when and how to write off claims.
• Ensure your policies are consistent with legal and ethical standards.
• Review your policies regularly to prevent unnecessary write-offs.

4. Make Timely Write-offs

• Once eligibility is determined, write off the claim immediately.
• Enter the write-off in your general ledger to avoid confusion later.
• Promptly mark unpaid claims as “not to be pursued” for future follow-ups.

5. Review and Audit Regularly

• Periodically audit your revenue cycle to identify trends in write-offs.
• Review your practice’s financial health to ensure you’re not overusing write-offs.
• Retrain your billing staff as needed to maintain accuracy and efficiency in the process.

One of those challenges is to handle your finances the right way. If you have a lot to do by yourself, things can sometimes get a bit messy. This can lead to poor revenue cycle management and lower profits.

Outsourcing your tasks to a healthcare RCM company, like BellMedEx is a smart choice! If you do this, you can save your energy and focus on what really matters, like giving great medical care and making sure patients are happy.

Lots of healthcare providers hire other companies to help with their work, like handling medical bills, sending in claims, and managing denials. Outsourcing your healthcare operations has many great benefits!

Here are some great reasons why outsourcing healthcare can help lower medical costs.

8 Reasons Why Healthcare Outsourcing Reduces Medical Costs?

Here are reasons that demonstrate how can you improve your revenue and how can you reduce your costs with healthcare outsourcing:

1️⃣ Cutting-Edge Tech at Affordable Prices

When healthcare groups outsource their admin tasks to a special third-party company, they can use the latest technology and skills without spending too much money. These companies spend a lot of money on the newest AI-powered diagnostic tools, telemedicine platforms, cloud computing, and other cool stuff. Things that would cost a lot for one medical practice to do all by itself.

The vendors offer these cool services at prices that are easy to pay for their clients. By helping many places, they get the most out of their investment in these technologies. The economies of scale make the costs feasible.

This helps small clinics and solo doctors give their patients the exciting benefits of high-tech medicine. Things like talking to doctors online, quick lab tests, and easy access to your health records. Without outsourcing, these services may be out of financial reach.

Also, getting help with regular tasks like billing, scheduling, and medical coding can save money. The vendors have smart workers and good ways to minimize expenses.

Strategic outsourcing allows healthcare firms to reallocate more resources to providing real care to patients. All while enabling access to leading-edge solutions that improve outcomes, experience, and affordability. It’s a win-win scenario for facilities, clinicians, and most importantly, patients.

2️⃣ Zero Maintenance Costs Guarantee Maximum Savings

If you run things yourself, you have to buy and take care of costly stuff like machines, software, furniture, and work areas. This ongoing maintenance costs a lot and can use up your resources fast. Every healthcare place has to deal with this cost when they run things on their own.

But if you let someone else handle these tasks, you can say goodbye to those maintenance costs for good! You don’t have to buy any software, hardware, or furniture. The outsourcing partner will take care of everything you need to get the job done well. You don’t have to stress about keeping costly equipment or spending money on workstations and spaces anymore.

If you cut out these maintenance costs, you’ll save a lot of money that will help your profits grow. You can use the money you saved from maintenance and equipment to make patient care better, buy new technology, invest in healthcare marketing, or offer more services.

3️⃣ Top-tier Data Security

One big reason is that outsourcing partners can provide great data security that follows HIPAA rules, and it’s a lot cheaper than creating it ourselves.

Making a data security system that follows HIPAA rules requires special skills and some money. Outsourcing partners located overseas have massive scale advantages that let them spread these fixed costs across many clients. They focus a lot on security because that’s their specialty. The end result is enterprise-grade systems that include disaster recovery, access controls, and sophisticated encryption.

It’s just too expensive for one American healthcare provider to handle this kind of data security all by themselves. Getting the right IT tools, having smart security folks, and sticking to rules can take a lot of time and energy away from their main job of helping patients. Outsourcing transfers that heavy lifting to partners who can do it better and cheaper.

Patients today really want their personal information to be kept safe and private. Outsourcing keeps things safe and lets American providers spend more time taking care of patients instead of stressing about technology. It’s a nice way to improve healthcare and save some cash too!

4️⃣ Cut Down Real Estate Costs

When a practice tries to manage every aspect of patient care in-house, they need more physical space for staff, equipment, and supplies. As more people need help, we also need bigger offices and clinics. Buying or renting this extra property can be tough on your wallet.

Outsourcing takes away the stress of needing to buy more property. Partners take care of things like billing, scheduling, and medical transcription remotely. Providers avoid ballooning real estate costs since outsourcing firms staff their own offices. This helps save a lot of money each year on rent or mortgage payments!

No need to fix up or make the current buildings bigger. Outsourcing certain administrative and clinical services allows practices to see more patients without adding new exam rooms or nursing stations. This makes the best use of the space that is already there without having to pay for renovations or new buildings.

5️⃣ Unbeatable Labor Costs

Outsourcing helps save money by letting healthcare facilities find skilled workers from around the world for much less than they would pay locally. Hiring and retaining top medical talent is incredibly expensive in the US – from salaries to benefits to training and more.

Outsourcing lets small and large scale healthcare practices work with talented people from countries where things cost less. So facilities can have complex tasks like billing coding, medical transcription, and imaging analysis done with precision for much less. The outsourcing provider takes care of all the HR management and operations for the healthcare provider.

6️⃣ Smooth Revenue Cycle Management

Think about being a caring healthcare worker who really loves helping patients feel better. But while you’re busy helping people and keeping them healthy, you also have to deal with the tricky and time-consuming process of revenue cycle management (RCM). This important part of healthcare can easily turn into a hassle, taking your attention away from what really matters – giving great medical care.

Managing money in a business can be tricky. It needs special skills and careful focus on every little thing. If you make a small mistake when sending in a claim, it can cause insurance companies to say no, reject it, or pay you less money. As a result, healthcare providers often struggle with cash flow issues, making it hard for them to keep their practices running and growing.

Luckily, there’s a way to make things easier for healthcare workers so they can focus on what really counts – taking great care of patients. By outsourcing revenue cycle management to specialized firms, healthcare providers can tap into a wealth of expertise and streamlined processes tailored to maximize reimbursements.

These medical billing outsourcing companies have a team of experts who focus on handling medical billing and coding. They know all the rules and guidelines really well. They make sure every claim is sent in perfectly, so there are no mistakes or rejections.

When healthcare providers let these experts handle their revenue cycle management, they can feel confident that their claims will be processed quickly and correctly. This means they will get paid on time and receive the most reimbursement possible from insurance companies. This helps reduce money worries and creates a better way to work. It lets healthcare providers buy new tools, offer more services, and give better care to their patients.

7️⃣ Personalized Services According to Your Needs

Healthcare is a fast paced field, with fast growing technology, regulations and changing needs as a practice. Healthcare providers have to keep changing to keep up with these updates.

Keeping up with the latest stuff can also cost more money for new changes and upgrades. Outsourcing companies always keep an eye on the newest market trends and make sure they are affordable for healthcare providers.

They can help you with your needs as you grow in any part of managing money coming in. Working with different healthcare providers at once helps keep costs low. So they offer these services for really low prices.

8️⃣ Better Focus on Core Tasks

Doctors and hospitals in the United States have a tough job. They need to give great care to patients but also keep the costs down. This is not an easy task because the healthcare world gets more complicated every year. We need to keep investing and changing to keep up with new technologies, rules, and what patients need. For one healthcare group, this can feel like a lot to handle.

Outsourcing key services is an elegant solution to help alleviate these pressures. Specialized outsourcing partners are dedicated to staying on the cutting edge of industry best practices. They put a lot of effort into training, technology, and making things better so healthcare workers can focus on their jobs. By leveraging their scale across multiple clients, outsourcing firms can offer these services at a fraction of the cost of building similar capabilities in-house.

Healthcare providers can tap into this expertise on-demand. Outsourcing partners are quick and adaptable, changing their services to fit what each client needs and wants. They work closely with the client, helping them with new ideas and growth every step of the way. This personalized approach allows healthcare companies to access world-class capabilities that would otherwise be out of reach.

Conclusion

Healthcare is a challenging field as you have to manage more than one task at the same time. As a healthcare provider this scatters your focus, depriving the core tasks. With outsourcing you can improve the quality of your services while reducing the costs.

If you’re looking for a trustable outsourcing partner for your medical office, who improves the quality of your tasks while decreasing the costs, BellMedEx is your go-to medical billing outsourcing company!

Well, you’re not alone!

The medical billing process can be really confusing for anyone, even doctors and nurses. At first, it might take some effort to figure out how it all works. Sometimes, you might even need help from an expert if you get stuck.

That’s where MEDICAL BILLING ADVOCATES come in.

These are people who are there to help patients like you and me. They make sure we understand our medical bills and can sort out any issues we have with insurance companies.

Below is a detailed guide to help you understand medical billing advocates more.

Who is a Medical Billing Advocate?

Medical billing advocates are professionals who help patients understand and deal with medical bills. Basically, they make medical bills easier to understand for patients. Here is what they do:

➜ First, they carefully check medical bills to make sure they are correct. They look for any mistakes or unfair charges along the way.

➜ Next, they talk to insurance companies about lowering the amount patients have to pay. They try really hard to get the best deal for patients.

➜ Also, they explain insurance policies and medical billing rules in simple terms. Things like copays and deductibles can be so confusing. Advocates break it down step by step so it’s easy to understand.

➜ Finally, they happily answer any questions patients have about their medical bills. Patients can feel totally lost trying to deal with complicated bills. Advocates kindly guide them through the process.

Medical Billing Advocates often work independently and charge patients a small fee. Their job is to take the stress out of medical billing. They make sure patients pay the right amount and understand what they are paying for.

8 Benefits of Hiring a Medical Billing Advocate

Medical billing advocates can help you (i.e the patients) in many ways.

They Are Experts In Medical Billing

First of all, they are experts in medical billing and insurance. This means they know all about medical codes, insurance terms, and billing practices. So if there are any mistakes in your medical bills or if you are overcharged, they can spot these errors and fix them.

They Can Save You Money

Another big benefit of using medical billing advocates is that they can save you a lot of money. For example, by checking your medical bills for errors, they can make sure you don’t pay more than you should. Also, they can negotiate with insurance companies to get you discounts.

They Help with Insurance Claims

What’s more, if your insurance claim is denied, medical billing advocates can help you appeal it. They will help you prepare and submit all the necessary documents to the insurance company. Plus, if you have any misunderstandings about your insurance plan, they can clear those up for you. They will also check if your claim should have been covered under your plan or not.

They Save Time and Reduce Stress

Lastly, dealing with medical bills and payment disputes can be really time-consuming and stressful, especially if you’ve just been sick. That’s why hiring a medical billing advocate is a good idea. They will handle all the communication with hospitals, doctors, and insurance companies for you. This saves you a lot of time and stress.

They Provide Personalized Support

Medical billing advocates take the time to understand the patient’s specific medical situation and financial capacity. Then, they create a custom action plan according to the patient’s needs and ensure avoiding any financial burden.

They Have Knowledge of Consumer Protection Laws

In addition, advocates know the consumer protection laws related to medical billing and save you from illegal practices like surprise billing or balance billing. For example, surprise billing is when you take services from an out of network doctor and you’re charged for the difference between what the insurance pays and the provider’s charges.

They Assist with Out-of-Network Issues

Furthermore, if you’ve received services from an out-of-network provider the billing advocate would help you understand the financial responsibility. They will also work on negotiating a lower rate with the healthcare provider or insurance company.

They Provide a Learning Opportunity

Finally, while working with a medical billing advocate you can learn all the ins and outs of the medical billing and insurance claims. Once your knowledge and understanding is improved you’ll be making better choices in the future saving you time, effort and money.

Best Ways to Find a Medical Billing Advocate

Do you need help with your medical bills? Finding a medical billing advocate can make things easier. But how do you find one? Let me tell you the best ways.

Professional Organizations

First, there are special groups that have lists of certified medical billing advocates. You can look at their lists and find someone good. Some of these groups are:

• American Medical Billing Association (AMBA)
• National Association of Healthcare Advocacy (NAHAC)
• The Alliance of Claim Assistance Professionals (ACAP)

Referrals

Next, you can ask people you know for suggestions. Talk to your doctor, insurance company, or even friends and family. They may know a great advocate. Asking people who have used an advocate before can help you make a good choice.

Online Search

Finally, you can search online for medical billing advocates near you. Many websites let you read reviews from other people. Just be sure to pick someone with lots of good reviews and fair prices.

FAQs

Are advocates for medical billing expensive?

Most individuals could afford them. Their billing approach affects their fees. For instance, should a medical billing advocate charge hourly, the fees could run from $75 to $350 per hour. Conversely, should they charge based on the money you save, the charges might be between 25% and 35% of the total saved.

What information do medical billing advocates need?

Medical billing advocates may request the following from you:

• Personal Information Details About Health Insurance
• Medical Bills
• Signed Authorization Form
• Medical Notes (should necessary)
• Payment Transcripts

Does every medical bill issue require hiring a Medical Billing Advocate?

No. By calling your insurance company or healthcare provider, you may fix basic medical billing problems on your own. You basically need someone to advocate for difficult problems, large costs, or when you lack time or information to handle things on your own.

For instance, some items come from the kitchen, others from the barista station, and some from the pastry display. So, you charge each item based on the prices you have set for different sections.

Revenue codes work in a similar way in medical billing. They help categorize the various services provided in different departments of a healthcare facility. This is important because each service has a different cost.

For example, let’s say a patient comes to the hospital for knee surgery. During their stay, the hospital will provide them with treatment, which may include a stay in the recovery room, physical therapy sessions, and medications. In this case, each service and procedure will have a different revenue code.

Meanwhile, this coding system helps pinpoint exactly where the costs are coming from. This way, insurance companies can easily understand and identify the services provided. Then, they can process claims accurately and ensure that healthcare providers receive the correct payments.

What is a Revenue Code in Medical Billing?

Revenue codes are like special numbers that help doctors and hospitals keep track of the different services they provide to patients. These numbers make it easier for insurance companies to understand what they are being asked to pay for.

Each revenue code is a three- or four-digit number that stands for a specific service. For instance, the code 0100 means “room charges for staying in the hospital,” while 0360 means “charges for using the operating room.” By using the right code for each service, the insurance company can easily see what they are being billed for.

Revenue codes help doctors and hospitals in a few key ways:

1. They make it easy to sort and group different services. This way, the billing is accurate and the insurance company pays the right amount.
2. Every service has its own unique code. For example, there are separate codes for room charges, treatments, and medications.
3. The codes give clear information to the insurance company. They can just look at the code on the bill and know exactly what service was provided.
4. With the right code, the insurance company knows precisely how much they owe for that service.

In short, revenue codes are really important for keeping things organized. They allow doctors and hospitals to send accurate bills to health insurance companies. Then, the insurance company can pay the correct amount because they understand the codes. With revenue codes, both sides know what services were given and how much they cost.

Revenue Codes vs. Medical Codes: What’s the difference?

Medical billing involves using various codes to document services provided and bill payers. Revenue codes and medical codes are two important types of codes with distinct purposes:

➜ Revenue codes categorize services and items

Revenue codes are 3-4 digit numeric codes that categorize services, procedures, and items provided to patients. They indicate the general type of service such as room and board, labs, physical therapy etc. Revenue codes allow healthcare providers to bill payers for these broad categories of services.

➜ Medical codes specify diagnoses and procedures

In contrast, medical codes like ICD-10 and CPT codes specify the exact diagnosis made and procedures performed. ICD-10 codes use a alphanumeric system to precisely define medical diagnoses while CPT codes use 5 digit codes to describe specific medical procedures.

Revenue codes tell what medical service was provided. Medical codes tell why and how.

For example, a revenue code may indicate that a patient received physical therapy. The CPT code would specify exactly what therapy services were performed, like therapeutic exercises or neuromuscular reeducation.

While both are used for billing purposes, revenue codes categorize services and medical codes provide granular clinical detail. Using them together provides the complete picture for accurate billing and reimbursement.

Structure of Revenue Codes

Revenue codes are structured as follows:

• First Digit: Indicate the broad service category (e.g., room and board, radiology, surgery).
• Last Two Digits: Provide specific information about the service or item.

Example:

• 0120: Indicates room and board, specifically a semi-private (two beds) room, inpatient.
• 0450: Represents emergency room services, general classification.

Revenue Codes Used in Different Healthcare Settings

As a healthcare provider, it’s really important to properly code and bill for the services you provide. This is the only way you can get paid by insurance companies like Medicare, Medicaid, and private insurers. Revenue codes play a big role in this process. They tell the insurance company exactly what type of service you provided on the claim form, like the UB-04 form.

For example, revenue codes are used to show if you did a surgery, took an X-ray, or ran a lab test. The insurance company looks at these codes to decide how much they need to pay you. So, by using the right revenue codes, you can make sure you get paid correctly for the care you gave.

Additionally, revenue codes help you keep track of how much money is being spent in different areas of your healthcare facility. This way, you can make sure resources are being used efficiently.

Now, let’s take a look at some of the most common types of revenue codes used in healthcare settings:

1). Revenue Codes for Inpatient Services

These codes help categorize the patient’s hospital stay, surgery, and medications. In this way, they help providers bill each treatment correctly.

• 0120: Room and board, semi-private (two beds), inpatient
• 0360: Operating room services, general classification
• 0250: Pharmacy, general classification (for medications administered during the stay)

2). Revenue Codes for Emergency Room Visits

These codes are used to categorize and bill the emergency room services. For example, patient registration, lab tests, and radiology.

• 0450: Emergency room, general classification
• 0300: Laboratory, general classification (for blood tests)
• 0320: Radiology, diagnostic (for chest X-rays)
• 0459: Other Emergency Room

3). Revenue Codes for Outpatient Services

These revenue codes track and bill the specific outpatient services. Hence, providers get proper reimbursement from the insurance company.

• 0420: Physical therapy, general classification
• 0430: Occupational therapy, general classification (if applicable)
• 0250: Pharmacy, general classification (for any medications prescribed)

4). Revenue Codes for Intensive Care Unit (ICU)

Revenue codes for the Intensive Care Unit fall under the 20x series. These codes categorize different ICU services based on the specific treatment and care.

• 200: This code is for general intensive care services, not a specific sub-category
• 201: For ICU services provided to patients recovering from surgery
• 202: For ICU services provided for non-surgical medical conditions
• 203: For intensive care services provided to children
• 204: For intensive care services related to psychiatric conditions
• 206: For less intensive, intermediate care services
• 207: For intensive care services related to burn injuries
• 208: For ICU services provided to trauma patients
• 209: Other types of ICU services not specified by the different codes

5). Revenue Codes for Pharmacy

Revenue codes for pharmaceutical treatments fall under the 25x series. These codes categorize medications and related services provided in a healthcare setting.

• 250: General pharmacy services that don’t fall into a specific sub-category
• 251: For generic medications
• 252: For brand-name medications
• 253: Medications dispensed for patients to take home
• 254: Medications used in conjunction with diagnostic services
• 255: Medications used in radiologic procedures
• 256: Medications used in clinical trials or experimental treatments
• 257: Over-the-counter medications
• 258: Intravenous solutions
• 259: Any other pharmacy services not specified by the different codes

6). Revenue Codes for Clinic

Revenue codes for clinic visits fall under the 51x series. These codes help categorize services provided in different clinic settings.

• 510: General clinic visits that don’t fall into a specific sub-category
• 511: Services provided at a chronic pain clinic
• 512: Services provided at a dental clinic
• 513: Services provided at a psychiatric clinic
• 514: Services provided in obstetrics and gynecology
• 515: Services provided at a pediatric clinic
• 516: Services provided at an urgent care clinic
• 517: Services provided at a family practice clinic
• 519: Any other clinic services not specified by the different codes

Conclusion

In short, revenue codes are very important for healthcare providers. They are a standard system to group and identify the different services given to patients. By using the right code, providers can make sure billing is accurate and see-through.

When used properly, revenue codes help providers in two big ways. First and foremost, they get the right payments from insurance companies and patients. Moreover, they avoid billing mistakes and confusion. As a result, the codes make billing work smoother and have fewer errors.

Revenue codes are a key part of medical coding and billing. Therefore, it’s essential providers fully grasp how the codes work, what they’re for, and how to apply them. By mastering these codes, providers can optimize billing operations, lower claim rejections, and maintain financial health for healthcare groups.

As healthcare changes, staying current on revenue code rules and updates is vital. To achieve this, providers should train staff and use advanced medical billing software to follow the rules and maximize revenue cycle management.

The good news is that there are ways to expedite the process. And this guide covers 13 proven tips to speed up prior authorization for medication. We’ll also answer some questions about prior auth. for medications.

Making Sense of Prior Authorization for Medication

Prior authorization (PA) for medication is a process in which healthcare providers get approval from a patient’s insurance company before prescribing certain medications. This approval is usually required for expensive drugs, those with a higher potential for misuse, or medications that have lower-cost alternatives.

How to Obtain a Speedy Prior Authorization for Medication

Healthcare providers must obtain prior approval from payers for specific medications. For that, they must check the patient eligibility, medical necessity, complete the prior authorization form, and submit it to the insurance.

➜ Check the Eligibility of the Patient for the Medication: Verify that the patient is eligible for the requested medication under their insurance plan.

➜ Assess If Your Prescription Needs Prior Authorization: Determine if the medication requires prior authorization with due diligence. You can also consult with the insurance provider and RCM partner like BellMedEx.

➜ Complete the Prior Authorization Form for Medication: Fill out the specific form provided by the insurance company, including relevant details about the medication and patient.

➜ Submit the Prior Authorization for Medication Request: Send the completed form to the insurance company through their preferred submission method.

➜ Track the Prior Authorization Request: Follow up to ensure that the insurance company processes the request and make any necessary adjustments.

Despite these clear steps, you may face many challenges during the prior authorization process, depending on varying payer requirements, constantly changing rules, and a lack of transparency.

6 Common Challenges in the Prior Authorization Process

These challenges can lead to delays. That’s why, we must understand them quickly before we jump into speeding up the process.

1. Increased volume of prior authorization requests for medication.
2. Shortage of skilled staff members.
3. Constant updates to payer requirements.
4. The process itself is labor-intensive, requiring multiple steps.
5. High workloads and stress levels among healthcare workers.
6. A lack of transparency and understanding of the process.

Let us now jump on the ways to tackle these challenges and expedite medication prior authorization.

How to Speed Up Prior Authorization for Medication

Speeding up the prior authorization process for medication helps ensure that patients receive timely care. Reduced delays help healthcare providers improve patient outcomes, reduce administrative burdens, and increase practice efficiency.

These are 13 practical tips to accelerate prior authorization for medication:

1. Create a Master List of Medications That Require Prior Authorization
2. Document Denial Reasons Thoroughly
3. Stay Informed of Industry Standards & Payer Requirements
4. Assign a Dedicated Team for Managing Prior Authorizations for Medication
5. Use EHR, Software, and Automated Systems to Submit & Track Requests
6. Maintain Clear Communication With Payers and Patients
7. Implement Documentation to Speed Up Prior Authorization for Medication
8. Educate Patients About the Prior Authorization Process
9. Request Expedited Reviews from the Payer For Urgent Cases
10. Create a Follow-up Plan for Pending Requests
11. Streamline the Entire Submission Process
12. Be Vigilant With Payers that Take Longer to Respond
13. Hire a Prior Authorization Specialist for Medication

Let us understand each method in a little detail now.

1. Create a Master List of Medications That Require Prior Authorization

Creating a master list of medications that require prior authorization helps streamline the process. Keeping this list organized and up-to-date helps healthcare providers quickly determine which medications need prior approval before prescribing them.

This proactive approach helps reduce delays, as providers can verify authorization requirements ahead of time and avoid unnecessary back-and-forth with insurance companies. Payers provide you this list, but you should be constantly checking it for updates. Also, ensure all staff members know this list well to avoid missing approvals and help patients get care faster.

2. Document Denial Reasons Thoroughly

Thoroughly documenting the reasons for prior authorization denials for medication helps prevent repeat issues. When a request is denied, record the specific reason given by the payer, including any missing information or required documentation.

This helps healthcare providers understand common issues that may lead to denials and make necessary improvements for future requests. Recording the reasons for denials helps when challenging decisions, as it clearly shows why the request was turned down.

3. Stay Informed of Industry Standards & Payer Requirements

The prior authorization for medication can vary greatly between different insurance companies and over time. Staying informed about industry standards and changes to payer requirements is important for smooth processing.

Regularly review payer guidelines, participate in industry webinars, and subscribe to payer newsletters to ensure you’re always up-to-date on the latest changes.

4. Assign a Dedicated Team for Managing Prior Authorizations for Medication

Assigning a dedicated team to handle prior authorizations for medication can speed up the process. When a specific team or staff member is solely responsible for this task, they become more familiar with payer requirements and can address issues quickly.

Specialization helps improve efficiency as the team gains expertise in navigating the complexities of prior authorizations. This approach also helps prevent burnout and ensure that the medication approvals are smooth.

5. Use EHR, Software, and Automated Systems to Submit & Track Requests

Leverage technology to speed up the prior authorization process for medication. Electronic Health Records (EHR), specialized software, and automated systems can streamline the submission and tracking of prior authorization requests.

These tech stacks allow for quicker submission, better organization of patient data, and real-time tracking of the approval status. Automated systems can also send reminders for follow-ups, reducing the chances of missed deadlines or duplicate submissions.

6. Maintain Clear Communication With Payers and Patients

Clear communication with both payers and patients is one of the best ways to speed up the prior authorization, especially for medication. When submitting a request, ensure that all required documentation is included and provide any additional information promptly if requested by the payer.

Also, keeping patients informed about the status of their authorization and any potential delays helps manage their expectations and reduces frustration. Regular, transparent communication ensures positive relationships with both parties.

7. Implement Documentation to Speed Up Prior Authorization for Medication

Effective documentation ensures that prior authorizations for medication are efficient. Ensure that clinical data, including diagnosis codes, medical history, and rationale for prescribing a specific medication, is well-documented and up-to-date.

Having this information readily available helps prevent delays due to missing or unclear documentation. Well-organized and detailed documentation makes the process smoother for both healthcare providers and payers, reducing the risk of rejections or the need for resubmission.

8. Educate Patients About the Prior Authorization Process

Educating patients about the prior authorization, especially for medication, helps set realistic expectations and reduce their frustration. Many patients are unaware of the complexities and time involved in securing prior authorization.

And this can lead to confusion and dissatisfaction. Educating them about the process and potential delays ensure you’re on the same page. This transparency also creates a long-term relationship between you and patients.

9. Request Expedited Reviews from the Payer for Urgent Cases

Healthcare providers must request an expedited review to speed up the prior authorization for urgent medication cases. If a patient’s condition requires immediate attention, healthcare providers must contact the payer to address the issue.

Payers often have protocols for handling urgent requests, which can help accelerate the approval process. By the way, prior authorization is not required for emergency cases.

10. Create a Follow-up Plan for Pending Requests

Having a follow-up plan in place for pending prior authorization requests for medication ensures timely approvals. Regularly checking on the status of pending requests can identify any issues early on, allowing you to address them before they result in delays.

A systematic follow-up plan, such as following up every 24-48-72 hours, ensures that no request slips through the cracks. It also allows healthcare providers to stay informed about the progress of the authorization process.

11. Streamline the Submission Process

Streamline the submission process for medicinal prior authorizations to reduce delays. You can use standardized forms, ensure all necessary documentation is attached, and submit requests through electronic portals when available.

A streamlined process minimizes the chance of errors, missing information, or incomplete submissions that could delay approval. The more organized and consistent the submission process is, the quicker the authorization will be processed, ultimately leading to faster patient care.

12. Be Vigilant With Payers That Take Longer to Respond

Some payers may take longer to respond to prior authorization requests for medication. Be vigilant when working with these payers and proactively follow up on any delays.

Track the response times of various payers to identify which ones tend to take longer and take extra measures to expedite the process. This vigilance ensures that no request is forgotten, and that providers can address delays even before time.

13. Hire a Prior Authorization Specialist for Medication

Hiring a dedicated prior authorization specialist for medication is a proven way to speed up the process. A specialist with experience in handling prior authorizations for medication can manage the complexities of insurance requirements efficiently.

And that’s where BellMedEx comes in to help you track requests, resolve issues, and communicate effectively with both payers and patients. We ensure swift prior authorization for medication to reduce the administrative burden on your staff.

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FAQs About Speeding Up Prior Authorization for Medication

In case we didn’t answer your question, you can contact us right away.

How long does prior authorization take for medication?

Most medication prior authorizations take 2-3 days, but this can change depending on the medicine type and insurance company. Some urgent requests might be approved within hours. For exact timing, it’s best to ask your insurance company directly.

How to check on a prior authorization for medication?

You can check your prior authorization status by calling your insurance company, checking their website or using their online portal (if available). The time it takes to receive a decision can vary depending on the insurer’s workload and internal processes. Regular follow-up helps you stay informed and fix any problems quickly.

What medications need a prior authorization?

Insurance companies usually require prior authorization for these medication-types:

• Brand-name drugs when cheaper generic options are available
• Age-specific medicines
• Cosmetic drugs
• High-dose medications
• Drugs with abuse potential
• Medicines not covered by insurance

Note: You can get the exact list of medication requiring prior authorization from your payers.

Prior authorization for medication denied, what to do now?

Follow these steps if prior authorization for medication is denied:

1. Find out why it was denied
2. Check for simple mistakes like wrong codes or spelling
3. Ask your doctor to provide more information if needed
4. Submit a new request or appeal the decision
5. Work with your doctor and insurance company to fix the issue

Speed Up Prior Authorization for Medication With BellMedEx

We can make your prior authorization process smoother and faster. Schedule a free consultation with us to learn how we can help your practice reduce denials and streamline your authorization workflow.

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This statement summarizes all charges, out-of-pocket expenses, insurance adjustments, and payments made during a certain period.

With a patient billing system and an integrated electronic health record (EHR) system, healthcare providers can track every service delivered, apply accurate insurance claims, and keep patients informed about their remaining balance.

❝ Regular and timely billing statements ensure that patients know their financial obligations without feeling overwhelmed. The goal is to send them often enough that patients are aware of their dues, but not so frequently that it becomes a nuisance. Balancing the frequency of statements can directly improve the efficiency of your practice management.❞

In this article, we’ll explore how often patients should receive billing statements, the key elements of these statements, their different formats, and how to generate them effectively.

Understanding Patient Billing Statement

A patient billing statement is a detailed document that summarizes the financial charges for the medical services provided by healthcare professionals to a patient. It includes a breakdown of treatment costs, doctor’s fees, hospital charges, lab fees, and any other services rendered. The statement also shows payments received, insurance adjustments, out-of-pocket costs, and the remaining balance due from the patient.

This important communication tool helps keep everything transparent between healthcare providers and patients by clearly outlining their financial obligations. The goal is to ensure that patients understand the costs, insurance claims, deductibles, and co-pays involved in their care.

❝ By receiving regular billing statements, patients can keep track of what they owe, what’s been paid, and any outstanding amounts. This ensures that both parties are on the same page when it comes to financial responsibilities.❞

Who Provides Billing Statements To Patients?

Billing statements are typically provided by the billing departments of healthcare providers such as hospitals, clinics, doctor’s offices, and other healthcare organizations. These departments are responsible for collecting all the necessary financial information, including treatment costs, doctor’s fees, insurance payments, adjustments, and patient balances.

In some cases, a medical billing service provider, like BellMedEx, is hired to manage this process. These full service medical billing companies help ensure that all data is accurately compiled, that payments are processed correctly, and that billing statements are sent to patients on time.

➜ However, the question remains: How often should these billing statements be sent to ensure a smooth billing process and maintain proper cash flow for the practice?

How Often Should Patients Receive A Billing Statement?

Patients typically receive their billing statements on a monthly basis, which is usually after 30 days or sometimes slightly later, depending on the billing cycle. However, in specific cases, such as patients undergoing long-term treatments or ongoing care, the frequency of billing statements may need to be adjusted to meet the unique needs of the treatment plan.

It’s important to remember that sending billing statements on a bi-weekly or weekly schedule can be highly effective for maintaining a smooth cash flow. If you rely solely on monthly statements, you may experience a rush of payments all at once, which can overwhelm your billing department and lead to more payment errors by patients.

➜ A more balanced approach is to divide your patient base into smaller groups and send out billing statements weekly. This allows for a steady flow of payments throughout the month, reducing stress on your billing team and improving the accuracy of payments received.

By organizing patients into different groups, you can ensure consistent revenue and evenly distribute the workload among your staff members.

Best Ways For Grouping Patients Before Sending Billing Statements

To establish an efficient patient billing workflow, you can organize your patients into different groups based on various factors. This helps streamline medical claim payment processing, ensure timely follow-ups, and improve the accuracy of your billing statements.

Alphabetical Grouping

Grouping patients alphabetically by the first letter of their last name is a simple and effective method. This works well when billing duties are assigned based on the alphabet, making it easy for your staff members to handle specific groups and send out patient billing statements efficiently.

Aging Buckets

Aging buckets divide patients into groups based on how old their balances are. For example, patients can be grouped into 0-15 days, 16-30 days, 31-60 days, and so on. This method helps prioritize older balances that require more immediate attention. By focusing on overdue accounts, you can improve cash flow and reduce delayed payments.

Insurance Carriers

Grouping patients by their primary insurance carriers is a more complex but useful method. This helps streamline the A/R follow-up process with different health insurance payers, as each insurer may have different billing requirements and timelines. While this method requires careful planning, it can ensure that each patient group is manageable and that medical billing and coding claims are processed efficiently.

Outcomes of Delivering Bi-Weekly and Weekly Billing Statements

By implementing bi-weekly or weekly patient billing statements, your healthcare practice can experience several positive outcomes:

Balanced Workload ➜ Sending patient billing statements more frequently allows you to distribute the workload across one or two weeks. This makes it easier for your billing staff to manage recent payments, insurance claims, and other billing tasks more efficiently, without feeling overwhelmed.

Stable Cash Flow ➜ Regular generation of patient statements ensures that payments are received more consistently. This helps your practice maintain a steady cash flow, ensuring that revenue comes in regularly, which is essential for the smooth operation of your healthcare practice.

Better Financial Planning ➜ When your practice has consistent revenue, it becomes easier to plan for the future. You can use the regular flow of payments to budget for expenses and make more accurate financial forecasts. This leads to better financial health and more effective practice management in the long run.

Improved Patient-Provider Communication ➜ More frequent physician billing statements keep patients well-informed about their outstanding balances. This can help reduce the time accounts stay overdue, leading to quicker payments and fewer payment delays. As a result, your relationship with patients becomes clearer and more transparent.

How to Generate a Patient-Friendly Billing Statement?

Managing patient billing requires following the right steps to generate a patient-friendly billing statement. Here’s a breakdown of the process:

1). Gathering Data

The first step in creating a patient-friendly billing statement is to collect all the necessary data. This includes information about the patient’s treatment, such as medical codes, insurance details, and the patient’s payment history. All this information should be recorded in the EHR system (Electronic Health Record) to ensure the data is up-to-date and complete. The treatment details include the dates of service, the procedures performed, and the medications prescribed. This data helps make sure that all services are correctly documented for billing.

2). Ensuring Data Accuracy and Verification

Once all the data is gathered, it’s important to verify the information to ensure it’s correct. Verification includes checking the date of service (DOS), confirming that the medical codes are accurate, and ensuring that insurance information is properly applied. This step is important to avoid mistakes or delays in the medical claims payment process.

3). Creating the Patient Billing Statement

After verification, the next step is to generate a billing statement which is patient-friendly. This is usually done with the help of Revenue Cycle Management (RCM) software, which formats the statement automatically. The billing statement must be clear and easy to read so that patients can easily understand their financial obligations. Using an automated system helps save time and reduce errors in the billing process, making it more efficient.

4). Conducting Quality Checks

Before sending the patient billing statement, a quality check is necessary. This involves a thorough review of the statement to make sure all information is correct. The totals and subtotals should be checked, ensuring that discounts and insurance adjustments are applied properly. This step helps avoid mistakes and ensures that the patient receives a correct and complete statement.

5). Delivering the Statement

The final step is delivering the medical billing statement to the patient. Healthcare providers can send billing statements through various methods, such as email, traditional mail, or through an online portal. The method of delivery should be chosen based on the patient’s preference, ensuring that the statements are sent in a timely and convenient way. Offering different delivery options increases patient satisfaction, giving them flexibility in how they receive their billing statements.

What are the Main Elements of a Patient Billing Statement?

To create clear and easy-to-understand billing statements, healthcare providers use several important elements. These elements help make the payment process smoother and more efficient for both the patient and the provider. Here are the essential parts of a patient billing statement:

1⃣ Demographic Details

This section includes important patient information such as the patient’s name, date of birth, address, and patient ID. Having accurate demographic details ensures that the billing statement reaches the correct person and the information is easy to identify.

2⃣ Services Detailed Information

This part lists all medical services provided, such as treatments, procedures, medications, and dates of service. It helps patients understand exactly what services they are being billed for, making the statement clear and transparent.

3⃣ Medical Codes and Descriptions

This section uses standard medical codes, like ICD-10, HCPCS, and CPT, to describe the medical services provided. Each code comes with a short description of the service. Accurate coding is important to ensure the correct reimbursement and smooth insurance claims.

4⃣ Cost Breakdown

This part shows the full cost of each service, including the total charges, any insurance adjustments, write-offs, discounts, and the patient’s financial responsibility (what the patient still owes after insurance payment). This clear cost breakdown helps patients see exactly what they need to pay.

5⃣ Payment History

This section details all payments made by the patient so far, including the date and the amount paid or still owed. This helps keep track of the patient’s payment history and ensures everything is recorded correctly for transparency.

6⃣ Due Date

The due date is the exact date when the patient’s payment is expected. Clearly stating the due date helps prevent confusion and ensures that payments are made on time.

7⃣ Contact Information

This section provides details about how the patient can contact the billing department if they have questions or concerns. It usually includes a phone number, email address, and sometimes the billing department’s physical address.

8⃣ Patient Responsibility

This part explains the amount the patient is responsible for paying after the insurance contributions and previous payments have been applied. It helps the patient understand their financial obligation and plan their payments accordingly.

Standard Formats for Sending Medical Billing Statements to Patients

Healthcare providers can use different formats for sending billing statements to ensure accessibility and convenience for all patients. It is important to balance technology with patient care and choose the most suitable delivery method for each patient. Below are the main formats of sending billing statements:

Electronic Statements (E-Statements)

Electronic statements, also known as e-statements, are sent to patients via email or made available on an online platform. This digital format is very efficient and easy to access, allowing patients to view their billing information immediately. E-statements can be automated, meaning healthcare providers can automatically generate and send billing statements. Patients receive their statements quickly and can view, download, or print them whenever it is most convenient. E-statements are also environmentally friendly, as they reduce the use of paper.

Paper Statements

Despite the growing popularity of electronic solutions, paper statements are still important for many patients. Paper billing statements are physically mailed to the patient’s address and include all the necessary billing information in printed form. This format is particularly helpful for patients who prefer physical documents or do not have regular access to digital platforms. To send paper statements, the billing department prints the statements, folds them, places them in envelopes, and mails them to the patient’s address.

Hybrid Approach

The hybrid approach combines both electronic and paper statements. This method allows patients to choose the format they prefer, offering flexibility. Some patients may prefer e-statements for their speed and convenience, while others might want paper statements for record keeping. The hybrid model improves patient satisfaction by catering to individual preferences and ensures that every patient receives their billing information in the most comfortable and convenient way.

What Happens if a Patient Fails to Pay a Billing Statement?

If a patient fails to pay a billing statement, it can lead to serious consequences for both the patient and the healthcare provider. Initially, healthcare providers will send payment reminders or follow-up notices, which may include late fees. However, if the payment is still not made, the account could be sent to collections.

Once an account is sent to collections, it can severely affect the patient’s credit score, making it harder for them to get loans, credit cards, or even housing in the future.

In fact, the Consumer Financial Protection Bureau (CFPB) reports that nearly 15 million Americans have medical bills listed on their credit reports. Many of these individuals come from low-income communities and regions in the southern United States, with a collective total of $49 billion in unpaid medical debt sent to collections.

It’s important for both healthcare providers and patients to understand the impact of unpaid medical bills and the potential consequences of failing to pay billing statements on time.

Key Practices for Generating Patient-Friendly Billing Statements

Generating patient billing statements can be challenging for healthcare providers due to issues like medical terminology, incomplete patient information, confusion around health insurance coverage, and more.

To make the process easier, we’ve compiled best practices that can improve billing statements and help avoid common problems.

Clear and Simple Language

Use simple language to explain the billing statement. Avoid using medical terms that might confuse patients. For example, add a description of the treatment and procedures in easy-to-understand words. This can help patients understand their medical bills clearly and reduce confusion.

Transparent Breakdown of Costs

Provide a detailed breakdown of costs in the billing statement. Show exactly what patients are being billed for by listing each service and its associated cost. This helps build trust and credibility with patients, as they will know exactly what they are paying for.

Multiple Payment Options

Offer various payment methods such as online payments, mail-in checks, and phone payments. Providing multiple options makes it easier for patients to pay their medical bills. Using online payment portals or automated phone payment systems can encourage timely payments and improve convenience.

Consistent Billing Schedule

Set a consistent billing schedule—such as weekly, bi-weekly, or monthly. This encourages patients to pay on time, helping you avoid delays in receiving payments and ensuring a smoother cash flow for your practice.

Digital Billing Methods

Whenever possible, use digital platforms to send billing statements via online portals or email. This makes it faster for patients to receive their statements and reduces the cost of mailing paper statements. Digital statements are environmentally friendly and more efficient.

Easy-to-Follow Payment Instructions

Provide clear payment instructions in the billing statement. Include due dates, payment methods, and contact information for billing questions. Simple and clear instructions make it easier for patients to pay their bills on time and avoid confusion.

Customized Billing Statements

Personalize billing statements by including the patient’s name, specific services, and dates of treatment. Personalization increases patient engagement, makes the statement more relevant, and can improve overall patient satisfaction.

Intuitive Statement Design

Design billing statements with readability in mind. Use large fonts, organized layouts, and highlight important details. A clear design helps patients quickly find important information, such as the due date or balance due.

Automated Payment Notifications

Set up automated payment reminders through email, SMS, or phone calls. These reminders help encourage timely payments and reduce delays in receiving payments. However, make sure the reminders are not too frequent, so patients don’t feel overwhelmed or frustrated.

Need an Automated Patient Statement Solution? Contact BellMedEx!

At BellMedEx, we first analyze your healthcare practice and patient workflows to provide the best automated patient billing solution. Here’s how we do it:

➜ Workflow Analysis: We evaluate your practice’s billing process, including patient visit frequency and insurance details.

➜ Customizing Billing Schedules: Based on our analysis, we recommend the best statement schedule for your practice—whether it’s weekly, bi-weekly, or monthly.

➜ Tailored Statements: Our system sends out patient billing statements automatically, making the process seamless and reducing errors.

With BellMedEx, your patient statements are tailored to your practice’s needs, ensuring timely payments and a smoother billing experience. Contact us to learn more!

Medical Claim Submission is one of the key steps in the medical billing process. It is a critical phase, as even a small mistake can trigger a chain of events that delays reimbursement.

In this guide, we will take a closer look at the physician claim submission phase, exploring the various aspects of the process. We will walk through the steps of healthcare claim submission, discuss the different types of claims, and much more.

The Basics of Claim Submission Process in Medical Billing

The phase in the medical billing process where a claim form is submitted to the insurance company by a healthcare provider or a medical billing company on behalf of the healthcare provider is known as “Claim Submission”.

Several steps lead up to this phase, and all of these steps, including the final submission, are collectively referred to as the Claim Submission Process. While the billing process as a whole is delicate, the submission of the claim requires a higher level of attention and responsibility.

The reimbursement amount a healthcare provider will receive, as well as the total time taken for the entire process, directly depends on this single claim form. Even a minor error can result in the insurance company denying the claim. A well-prepared claim not only minimizes errors but also increases the likelihood of receiving the maximum reimbursement from the insurance company. Therefore, the overall quality of the claim matters as much as its accuracy.

What is Included in a Medical Claim?

A medical claim has key details of the patient’s diagnosis that helps a healthcare provider with correct processing of the patient’s claim and get reimbursement from the insurance company.

Each part of the claim form has a specific job, like listing the patient and provider, describing the services given in the form of CPT and ICD-10 codes, and showing the total costs.

Knowing what’s in a medical claim is important for both doctors and insurance companies to make sure payments are made on time and are accurate.

Patient Information

This section includes basic demographic details about the patient, such as their name, gender, date of birth, and the purpose of the visit.

Provider Information

This section contains information about the healthcare provider, including their name, address, and identification number (NPI). It also includes details about the facility where the services were provided.

Procedure Information

Here, you’ll find the diagnosis codes (ICD-10 codes) and the services provided at the facility, identified using CPT codes.

Charges

This section outlines the expenses for the services provided at the medical facility, detailing what the healthcare provider expects to receive from the insurance company.

Insurance Information

This section includes detailed information about the insurance, such as the name of the insurance company, the coverage details, and the policy number.

Steps of the Medical Billing Claim Submission Process

Claim submission is one of the most crucial steps in the medical billing process, serving as the central point of the entire billing cycle. Let’s take a quick overview of the claim submission process:

Step 1: Patient Registration

The medical billing process begins with the registration of the patient. During this stage, the medical office collects basic patient information such as:

• Name
• Age
• Gender
• Insurance Information
• Purpose of Visit
• Medical History
• Financial Information

Following this, the insurance is verified by professional billers, who determine the insurance status and coverage in relation to the required treatment. This information is then shared with the patient.

Step 2: Determination of Financial Responsibility

In some cases, insurance companies do not cover the entire cost of treatment. When this happens, the patient becomes responsible for the remaining balance. To ensure transparency, it’s important that the patient is informed in advance about any financial responsibilities.

During this step, the financial responsibility for the services to be provided is determined and communicated to the patient. This ensures both the healthcare provider and the patient have clarity from the start, allowing the patient to decide whether they can afford any copayments. The treatment is then provided based on the agreed terms.

Step 3: Medical Coding

Once the treatment has been provided, the diagnosis and procedures are translated into codes through medical coding. There are two main types of medical coding:

➜ ICD-10 Codes: The International Classification of Diseases (ICD) codes are used to represent the symptoms detected and treated by the healthcare provider. Currently, ICD-10 codes are in use, and ICD-11 codes are expected to be implemented by 2025.

➜ CPT Codes: Current Procedural Terminology (CPT) codes, developed by the American Medical Association (AMA) in 1966, correspond to the specific treatments or procedures given to the patient.

These codes are crucial for determining reimbursement amounts, making them an essential part of the claim process. The medical coding service is completed by a professional medical coder.

Step 4: Superbill Creation (only applies to out-of-network healthcare providers)

After the patient receives treatment and medical coding is completed, the next step is to compile the codes and create a superbill. This superbill serves as the foundation for the medical claim form.

The superbill contains the patient’s basic demographic information, medical history, healthcare provider details, and clinical information. It also includes the medical codes that represent the symptoms diagnosed and the treatments provided.

*Note: A superbill is created if the patient has seen a doctor outside of those affiliated with their insurance company, aka “out-of-network provider”.

Step 5: Claim Submission

The medical biller then carefully prepares the claim form. Once the form is completed, the biller reviews it thoroughly to ensure compliance with payer and HIPAA standards, including medical coding accuracy and proper formatting.

The claim form is then submitted to the relevant insurance company, with the expectation of timely reimbursement. The most commonly used claim forms are CMS-1500, UB-04, and ADA Dental forms.

If the claim is error-free (a clean submission), payment is typically processed by the insurance company as soon as possible. However, if errors are found, additional steps may be required to resolve the issue via a Coding Claim Denial Management Service.

Methods of Claim Submission

There are two major methods for submitting medical claims:

Electronic Submission

Thanks to advancements in technology, claim submission can now be done electronically. This method has become more popular than paper submission due to its efficiency. Electronic claims, submitted through a clearinghouse, are faster and less prone to errors, allowing for a more streamlined and accurate submission process.

Paper Submission

In paper submission, medical claim forms and supporting documentation are physically mailed to the insurance companies. While electronic claims have largely replaced paper submissions, many healthcare providers still use paper claims in certain circumstances, such as when the insurance company does not accept electronic submissions, when there are technical issues with electronic systems, or when a specific type of claim requires paper processing due to the nature of the service or provider.

Difference Between Electronic and Paper Claim Submission Process

Top 10 Reasons for Claim Denial by Insurance Companies

Here are the major reasons why a claim might be denied by insurance companies in medical billing:

Wrong Information

One of the most common reasons for claim denial is incorrect or incomplete information. This could involve missing details or errors in the information provided on the claim form.

Late Claim Submission

Claims may be denied if they are not submitted within the required timeframe. Some insurance companies allow 90 days for claim submission, while others may require it within 30 days. It’s important to be aware of the deadlines set by your insurance company.

Errors in Coding or Billing

Medical billing is a complex and precise process. Any error in medical coding or billing can result in a claim denial. It is essential to double-check the codes and billing details to ensure accuracy and avoid denials.

Services Not Covered

Insurance companies only cover a specific set of medical services. If the services provided are not included in the patient’s policy, the claim will be denied. Be sure to review the patient’s policy to confirm coverage before submitting the claim.

Unnecessary Medical Services

Claims can be rejected if the insurance company deems the treatment unnecessary. In such cases, you may need to resubmit the claim with additional documentation or a letter from the doctor justifying the need for the treatment.

Pre-existing Conditions

Some insurance policies exclude coverage for pre-existing conditions. If the treatment is related to a pre-existing condition, the claim may be denied. It’s essential to understand your policy’s terms regarding pre-existing conditions.

Expired Policy

Claims submitted after a policy has expired are often denied. To avoid this, consider setting up automatic payments to ensure your premiums are paid on time, keeping your policy active.

Lack of Pre-approval

For certain services, insurance companies require pre-approval. If this approval is not obtained before the service is provided, the claim will likely be denied. Always check in advance which procedures require pre-approval.

Duplicate Claim Filed

Claim submission can be a hectic process, and duplicate claims are a common mistake. Keeping a record of all submitted claims can help prevent the error of submitting the same claim more than once.

Claim Lost by the Insurance Company

While rare, claims can be lost by the insurance company itself. This unfortunate situation can lead to a denial. To avoid this, always keep a duplicate of the claim for your records.

Wrapping Up

Claim submission is the backbone of the medical billing process. The goal with every claim submission is to achieve a clean submission—one that is free of errors and fully compliant with all requirements. While it may not be possible to achieve a 100% clean submission rate every time, even a small increase in your clean submission rate can yield significant benefits.

Understanding the claim submission process is crucial for anyone working in the medical billing or healthcare industry. Familiarity with the entire procedure will help you minimize errors that can hinder the best results and significantly improve your chances of successful reimbursement.