The main steps in the hospital billing process are (a) preregister or register patients, including scheduling appointments and establishing the patient's account; (b) establish financial responsibility for visits by explaining the facility's payment policy to patients and verifying their insurance coverage and any precertification requirements; (c) check patients in by copying their insurance cards and other identification cards, collecting copays and/or deductibles, and obtaining the required consents forms, such as a HIPAA Privacy Disclosure and the hospital's Notice of Information Practices; (d) check patients out, providing them with postdischarge care instructions if required; (e) review coding compliance by checking the accuracy of the diagnosis and procedure codes recorded in the patient's medical record and verifying that they are logically connected; (f) check billing compliance by collecting the patient's charges accumulated during the hospital stay and verifying them against the charge description master, the patient's medical record, and knowledge of the payer's requirements; (g) prepare and transmit claims using the facility's patient accounting system, including the use of a scrubber to test claims before transmitting them; (h) monitor payer adjudication to ensure that bills are paid on time and in full, including claim follow-up and payment processing; (i) generate patient statements for remaining balances when health plan payments do not pay the bills in full and for self-pay patients; and (j) follow up on patient payments and handle collections, including writing off uncollectible accounts. The first four steps deal with the patient's visit, the next three steps with the patient's claim, and the final three steps with post-claim activities.
During preregistration or registration, the following information is gathered and entered into the patient accounting system to establish the patient's account: personal data, basic billing data, medical information, an account number, and a medical record number.
A routine charge is the total of the costs of all supplies that are customarily used to provide the service. An ancillary charge is made for each specific service that is used to treat the patient in addition to routine charges, such as for anesthesia and blood administration.
The charge description master (CDM) is a computerized list of charge codes and associated data for all services the facility offers. Each entry identifies the hospital department and subcategory, the charge code for the service, the description, a medical code (when required), a standard claim form revenue code (RC), and the price. When the
codes for services from the various charge slips are entered into the patient accounting system, the code automatically posts the correct charge to the patient's bill.
Billing errors include (a) billing for services or supplies that are not documented in the patient's medical record; (b) billing for services that are insufficiently documented in the patient's medical record; (c) billing twice for the same service (double billing); (d) billing for medically unnecessary services; (e) billing for services that are included in other charges; and (f) billing inaccurate information about providers or the wrong providers.
The advantages of using information technology in the hospital billing process, such as electronic health record (EHR) systems and electronic input devices during the admissions process, are (a) immediate access to health information; (b) computerized management of physician orders; (c) access to research for decisionmaking processes; (d) automated alerts and reminders; (e) electronic communications and connectivity; (f) patient support tools such as patient education on health topics; (f) administrative reporting tools; and (g) error reduction. The biggest disadvantages are (a) the cost of implementing the system; (b) the large learning curve for staff in becoming proficient with the new technology; and (c) the potential risk to the confidentiality and security of patient data.
