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Medical Billing Process
Article contributed by offers information on different services that can be outsourced to India. They facilitate the outsourcing process by helping source vendors to carry out various outsourcing requirements ranging from medical billing to customer support.

Key Points:
Doctor's office
Charge Entry
Claim Transmission
Carrier adjudication
Month End Report

This module takes you through the simplified process with the intent of explaining to you, the functioning on one whole unit that takes place in Medical Billing.

Doctor’s Office

A patient visits a doctor and explains his/her problem. The doctor then diagnoses what could be the ailment and then draws a chart as to what treatment needs to be rendered, for example if a patient John Doe has stomach pain, then a sequence chart would be drawn up by the provider to explain the treatment pattern.

Documentation at the Front Desk

The patient hands over his card copy, of which insurance he has, in this case we would assume Humana Gold Plus. On the card copy the office manager needs to verify if a referral or pre-authorization needs to be obtained and then contact the respective Primary care physician (gatekeeper) and get this documentation.


Demographics, superbills/charge sheets, insurance verification data and a copy of the insurance card i.e. all the information pertaining to the patient, is sent to the billing office or to our office.

Billing office scans the source documents and saves the image file to an FTP site or on to their server under pre-determined directory paths.

Our Scanning department retrieves the files. We have developed an in-house software called BISSY(BILLING INTEGRATED SUPPORTING SOFTWARE). Using this software, scanning team splits the images from a file and arrange them according to patient names.

Files are sent to the appropriate departments with the control log for number of files and pages received. Illegible/missing documents are identified and a mail is sent to the Billing office for rescanning.


Pre-coders then enter the key-in codes for insurance companies, doctors and modifiers.
Pre-coders also add insurance companies, referring doctors, modifiers, diagnosis codes and procedure codes that are not already in the system.


Coding team assign the Numerical codes for CPT(Current Procedural Terminology) and the Diagnosis Code based on the description given by the provider.

Charge Team

In this department we have competent individuals who would first enter the patient personal information from the Demographic sheets. They also would check for the relationship of the Diagnosis code and CPT. Then create a charge, according to the billing rules pertaining to the specific carriers and locations. All charges are accomplished within the agreed turnaround time with the client, which is generally 24 hours.


The daily charge entry then needs to be audited to double check the accuracy of this entry, in other words, this is the check and balance to make certain the billing rule is being followed accurately. Also this department verifies for accuracy of the claims based on carrier requirements to ascertain a clean claim.

Claims Transmission

Claims are filed and information sent to the Transmission department.
Transmission department prepares a list of claims that go out on paper and through the electronic media. Once claims are transmitted electronically, confirmation reports are obtained and filed after verification.

Paper claims are printed and attachments done, if necessary, put into envelopes and sent to the US for postage and mailing. Transmission rejections are analyzed and appropriate corrective action is taken.

Carrier Adjudication

The carrier Utilization Review department would then review the claim and after their edit checks, the claim would then be adjudicated on and processed for payment. Then check and an Explanation of Benefits are sent to the provider.

Cash Application

Cash Applications team receives the cash files (Check copy & EOB) and apply the payments in the billing software against the appropriate patient account. During cash application, overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are informed to the Analysts.


AR analyst are the key to any group. The claims are researched for completeness and accuracy and work orders are set up for the call center to make calls. AR analysts are responsible for the cash collections and resolving all problems to enable the account to have clean AR.

They also research the claims denied by the carriers, rejections received from the clearing house, Low payment by the carriers and appropriate actions are taken. Analyst reviews for global patterns and bulk problems are solved at one instance.


This is the hub of activity around which Medical Billing operates, where the caller would call up Insurance and verify if the claim is with the carrier and what is the current status of it. Whether it is being processed for payment or denial, based on his inputs the analyst goes to work, and gets the required pre-requisites needed, in case of payment he would compile a list of payment details or if denied then corrective action needs to be initiated.

Calling team receives work orders from the analysts and initiate calls to the insurance companies to establish reasons for non-payment of the claims. All reasons are passed on to the Analysts for resolution.


This scenario is then compiled in Excel, for future use when similar problems occur in any other specialty. This information needs to be made available to anyone who needs to review past records to identify solutions to any particular present scenario.

Month End Reports

End of the month we would need to run Doctor Financials and other procedure code usage reports, aged summary reports so that we would asses the momentum that has been achieved this month, and if not see where there is a pattern of non payment.

In this way we could once again tackle any bulk pending issues.
Any claim beyond the 60 day pending needs to be acted upon, if it is pending for clarification then that needs to be informed to the respective account manager at the center so that remedial steps could be initiated.

Medical Billing Workflow

Medical Billing Workflow

Click the diagram for a larger view

Confidentiality of Information

Electronic processing and transfer of data via multiplex or /router/ modem is encrypted and password protected to ensure privacy and confidentiality. Dedicated leased lines and Firewalls ensure security of data.

We ensure compliance of The Health Insurance Portability and Accountability Act of 1996 (HIPAA). We respect all patient information provided by our client and will not disclose any information.

Confidentiality of patient and practice information is assured. GIS has zero tolerance policy for any breech of confidentiality. Records are kept secure and all appropriate laws are observed for handling the release of information.

Hope this module gave you a brief idea of what goes on in a single unit of medical billing. offers information on different services that can be outsourced to India. They facilitate the outsourcing process by helping source vendors to carry out various outsourcing requirements ranging from medical billing to customer support.

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