Imagine operating your practice without medical billing guidelines. Apart from the chaos it would whip up, endless claim denials and federal penalties would be piling up at your desk, leading to an unimaginable and unavoidable revenue loss.

Medical billing and coding services have been around for decades. It would be nearly impossible to run a practice without them smoothly. A medical billing process comprises a series of mandatory steps that ensure that healthcare professionals are being paid for their services.

Here are the general guidelines for a medical billing process used by medical billing services Pennsylvania and across the US.

What is Medical Billing:

It is a systematic process of submitting claims and getting reimbursement for the rendered services to the patients. Medical billers and coders work in tandem with healthcare providers, patients, and insurance companies.

While the jobs of medical billing and coding specialists are entirely different, they work in conjunction with one another. For instance, when a patient visits the doctor, it’s the coders’ job to translate every bit of information into alphanumeric codes, which the billing department then uses to submit a claim and receive payment from the patient’s insurer.

There should be a constant communication flow between the key stakeholder; patients, the provider, and the insurance company In order for the smooth running of the process. On average, it takes 40 to 50 days to complete a billing cycle. However, it can be flexible depending on the services rendered.

10 Steps in Medical Billing Process

  • Register the Patient:

The first step in a medical billing process is registering the patient. In order to do that, you need to collect their information, such as name, age, address, policy number, contact details, and insurance provider.

Create a checklist of all the essential details so you don’t miss critical inputs. Before filing the form, cross-check all the information as well as eligibility issues. Nowadays, most billing services use EHR or EMR solutions to make the patient registration process a breeze.

  • Verify Insurance Plan:

Once you successfully register the patient, you need to check their insurance plans to determine what treatments are covered under their plan. This is a critical step and must be done cautiously, as insurance companies tend to change their rules and policies from year to year. Also, as a healthcare practice, you must stay updated on the latest requirements to avoid claim rejections.

  • Create Superbill:

When the patient arrives at the practice, they are required to fill out forms for the file or update information if they are a returning patient. This form will create the basis for your claim submission and reimbursement. Here is a quick rundown of the information your superbill must have:

  • Patient information
  • Full name
  • Date of birth
  • Contact information
  • Insurance information
  • Visit information
  • Date of visit
  • All relevant codes (CPT & ICD)
  • Duration of visit
  • Fee charges
  • Provider information
  • Full name
  • Location
  • contact information
  • National Provider Identifier (NPI) Number
  • Referring Provider Name and NPI
  • Signature

Once the patient checks out, a coder translates the visit into appropriate codes and creates a superbill after compiling all the information.

  • Prepare and Submit a claim:

With the help of the superbill created in the previous step, the medical biller will prepare a claim to submit to the patient’s insurer for reimbursement. Once the biller prepares a claim, they must review it to cross-check that all the details are correct and comply with HIPAA rules and the payer’s policies.

Once it is clear that all the information is correct, including the codes, the next is the submission step. For private insurers, the claims are electronically submitted to the third-party vendor, who acts as a liaison between the payer and the practice. While for high-volume payers like Medicaid and Medicare, the claims are directly submitted by the healthcare provider.

  • Monitor Payer Adjudication:

Claim adjudication is a process in which the insurer evaluates a claim and determines if it’s compliant and valid to proceed to the reimbursement. However, not all claims get accepted. The possibility of claim denial and rejection always lingers during the evaluation process.

For instance, if the claim gets accepted, the insurer will reimburse as per the agreement. A rejected claim must be re-submitted after correction. Lastly, a denied claim occurs when the payer refuses to pay for the services.

  • Create Patient Statements:

Once the claim has been accepted, the insurer pays its share and passes the rest of the amount to the patient in a detailed statement. It will include the list of the services rendered to the patient, their costs, the share covered by the insurer, and the outstanding payment to be made at the patient’s end. If everything goes smoothly, the patient will cover their share and get done with the process. However, this is not always the case.

As a biller, it’s important to be aware of the challenges at this step and how to effectively deal with them to keep the cycle time as small as possible.

  • Follow-Up:

The last step of a medical billing process is ensuring the bill has been paid. It is a biller’s job to follow up on claims and send payment reminders if needed.

Once the patient receives the statement, it is the provider’s job to make the payment process as simpler and painless as possible. This would help encourage patients to pay promptly. Setting up an online payment system through the patient’s portal will make the job easier, allowing patients to pay at their convenience.


As complex as the medical billing process seems, it is actually possible to get through it smoothly. The key is to document all essential information accurately and review the claim before submission to catch any errors. This drastically reduces the reimbursement time and the overall billing cycle.

Top medical billing services Pennsylvania follow the same steps to bill their patients and receive timely payments. Make sure you follow the same pattern to speed up your billing process.


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