Learn the Medical Billing Process Step by Step

7. Clean up and file your claims.

Errors are familiar with all the codes and numbers that go into claims. You can catch most, if not all, of these problems with claim scrubbers before you file your claims. These automated software systems are aware of the specifics of your claims.


It’s time to file your claims after they’ve been cleansed. If your patients have Medicare or Medicaid, you can usually file your claims with these government payers directly. Direct filing may be easier if you have good relationships with only one to three payers. In all other circumstances, using a clearinghouse is preferable. These third-party businesses will reformat your cleansed claims for the proper payer. You won’t have to deal with rejected claims because you filed a lawsuit in one payer’s format to another.

8. Monitor payer adjudication.

The adjudication process begins after the payer gets your claim. The payer chooses how much of your claim will be paid and whether your lawsuit will be approved, rejected, or denied during this procedure. Rejections are frequently the result of coding problems rather than a payer’s refusal to reimburse you.

Your rejections will frequently include recommendations on how to correct your mistakes. You can immediately refile your claims and (hopefully) be reimbursed if you follow these guidelines. Of course, even if your claims are flawless, insurers may reject them. In this instance, your billing staff should evaluate the payer’s decision for potential mistakes, which will often be detailed. If you find any problems, you can start the appeals procedure, which can be costly and time-consuming.

You have two choices if your claim is refused because the insurer does not cover your services. You can notify the patient of the denial and inform them that they now owe you the money that was not reimbursed. Alternatively, if the patient has secondary insurance, you can claim their secondary plan for the uninsured expenditures.


9. Distribute patient statements.

If a non-zero debt occurs from a claim submission for a patient who does not have secondary insurance, you must send the patient a statement outlining their charges. You should also send a benefits explanation explaining what the patient gets and does not get with their insurance plan. This way, they’ll understand why, despite having insurance, they still owe you money.

Payment instructions and due dates should be included with your patient statements. You can also offer information on how the patient can file an appeal if they so desire. Denials are frequently managed by medical clinics or their outsourced billing teams, but patients may still wish to file their appeals.

10. Seek payment.

If your claim were authorized, you would seek compensation from the payer. Remember that the wait between claim approval and reimbursement can be lengthy. Proper tracking of your accounts receivable can allow you to identify which claims have gone too long without being paid. You must follow up on these claims until you are paid.

The payment obligation for denied claims is on the patient. Your medical billing team should repeatedly contact the patient until they pay. If the patient continues to fail to pay, you may want to consider referring the patient to a debt-collecting agency.