Medical billing

One of the most complicated administrative practices in the medical profession is medical billing. Medical billing is an integral administrative aspect of the medical profession, and it is such a comprehensive task that it requires a whole new department of professionals who are proficient in billing practices in order to deliver results in a swift and efficient manner.

General medical billing process

  • The medical billing process begins with the patient registration.
  • During this time necessary information such as the patient’s insurance, past illnesses, any ongoing treatment, and other such medically relevant details are gathered.
  • The billing department verifies the insurance eligibility before each appointment, and the patient is notified of any changes in the insurance during the course of their consultation/treatment.
  • Once the patient is under the doctor’s care, the medical billing and coding processes come into play. Each diagnosis, treatment and medical procedure is carefully recorded and coded, using the correct CPT and HCPCS code modifiers. This will result in the patient’s claims being settled effectively.
  • The next step is claims submission, where the bills are sent to the insurance company for payment. This claim has to adhere to the format guidelines that are set by the specific insurance payer.
  • Failure to follow this set up will result in a rejected claim, thus requiring the billing team to go over the entire process once again.
  • Once the insurance companies have reimbursed the bills, the patient is presented with the payment information, along with information about any out of pocket expenses that the patient will have to bear.

Understanding claims
Medical billing claims ought to adhere to the HCC (Hierarchical Condition Categories) model, which has been implemented by the CMS (Center for Medicare and Medicaid). CMS HCC is aimed at adjusting capitation payments, thus reducing expenditure risks for the patients.

CMS HCC is accumulative in the sense that a single patient can be assigned with more than one HCC category. However, the HCC adheres to a hierarchy that determines which HCC code overrides another HCC code.

Documentation is very important when it comes to HCC. Since the diagnoses fromprevious years are used to calculate the current payments to the Medicare Advantage plan, the HCC should be recorded at least once every 12 months. Failure to do this will result in the generation of a six month revenue gap for that particular plan.

Creating claims

Medical billing comprises primarily of creating and processing billing claims. Hence the billing professionals should be well versed about the codes and types of claims an insurer entertains. This will help separate the “good” bills from the “bad” ones, thus resulting in reduced redundancy during the billing process.

A medical biller ought to be in constant touch with the insurance payers, patients and other associated bodies involved in reimbursing the bills. The billers are required to provide the patients with Explanation of Benefits, which essentially breaks down the bill to its individual elements and educates the patients about the cost of procedure, treatments, etc.

Why MedConverge

Hiring a professional medical billing company will help reduce inaccuracies, thus reducing chances of your medical claims being rejected by the insurance companies. With a dedicated staff that is proficient in the latest coding procedures, MedConverge ensures that your billing processes are followed through diligently, ensuring optimal billing efficiency.


  1. 6 Key Steps of a Successful Medical Billing Process. (n.d.). Retrieved March 17, 2017, from M-Scribe Medical Billing:
  2. Everything you need to get started in Medical Billing & Coding. (n.d.). Retrieved March 17, 2017, from Medical Billing & COding Certification:
  3. HCC Definition. (n.d.). Retrieved March 17, 2017, from
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