Medical billing

Medical billing is the process by which healthcare providers such as hospitals and physician offices submit claims to health insurers for reimbursement of services rendered. CPT codes like 99213 for office visits enable billers to translate medical records into standardized billing data.

Patients receive Explanation of Benefits (EOB) documents from insurers, detailing amounts paid and any remaining balances. Errors in coding or documentation can cause claim denials, requiring providers to resubmit corrected claims for payment.

The Health Insurance Portability and Accountability Act (HIPAA) mandates electronic transactions and protects patient information during billing. Clearinghouses, such as Availity and Change Healthcare, transmit electronic claims between providers and payers, according to YourInsurance.info.

Out-of-network charges often result in higher patient bills due to balance billing, exemplified by surprise emergency room bills averaging $628 in 2022 according to KFF. Medical billers must verify patient insurance eligibility before submitting claims using tools such as real-time online verification platforms.

Appeals processes allow patients and providers to dispute denied claims with insurers by supplying supporting medical documentation. Insurers typically pay the allowed amount for covered services within 30 days according to prompt payment laws in states like California and Texas.