Medical Billing Basics : Medical Assistants Class



  • Submitting claims to insurance companies to receive payment for services rendered by a doctors office or hospital is

    medical billing

    Rationale: Medical billing is an important role for the medical assistant. All services that are provided to a patient while they are in a medical facility should be documented, and all reimbursable services should be submitted to the insurance companies for the office to receive maximum payment.. It is vital that the correct patient demographics, insurance information, and services provided are present on the patient's bill so that payment is received in a timely manner.

  • A patient's demographic information, as well as medical treatment provided to them, can be found in the:

    medical record

    Rationale: There should be a medical record for each patient that visits your medical facility. This record should contain current demographic information for the patient, as well as their insurance information, and any medical treatment that provided to the patient. A medical record could be a paper chart, and electronic record, or a combination of both.

  • Prior to providing services to a patient in the medical setting, the patient's insurance company should be contacted for:

    verification of eligibility

    Rationale: It is important to contact the insurance company for a verification of eligibility for a patient prior to providing them with services. Many policies can change throughout a year, and may not be active just because a patient has an insurance card in their possession. It is important to always remind patients that an insurance policy is not a guarantee of benefits, and that the patient is ultimately responsible for their bill if insurance does not pay.

  • When claims have been processed by the insurance company, they will notify the medical office of the transaction by sending an:

    Explanation of Benefits (EOB)

    Rationale: Once an insurance company has processed a claim, they will send an Explanation of Benefits (EOB) to the medical facility, as well as the patient. The EOB will explain what amount is allowed and reimbursable, as well as what is the patients responsibility, and any payment provided to the office from the insurance policy. It is important to keep a record of the EOB's received for each patient in an organized manner within the office for bookkeeping, and as reference for proof of payment.

  • A claim that is found to not be payable by an insurance company is returned as:


    Rationale: There are several reasons that a claim may be returned unpaid from an insurance company. When a claim is denied, it is usually because the terms of the policy do not allow the services for which you have submitted. This may be because of the way you submitted them, or that not enough medical information was given to support the treatment. This does not mean that the claim will not be paid, because services that are denied can often times be resubmitted or corrected if the services should have been a covered expense according to the patients policy. If the final result of a claim is that it is denied because the expenses are not covered under the patients policy, the billed amount is intimately the patient's responsibility.

  • A claim that is returned unpaid because there was an error in the information submitted to the insurance company is returned as:


    Rationale: A rejected claim is one that never really gets processed by the insurance company. There is usually an error somewhere in the claim that prevents it from even getting to the adjuster for payment. This may be something as simple as a wrong patient birth date, address, or ID number. These claims will eventually be processed once the error is fixed, and the claims are resubmitted to the insurance company.

  • When a patient has more than insurance policy, the insurance company that is responsible for paying the claims first is known as:


    Rationale: It is not uncommon for a patient to have more that one insurance policy to process their medical claims. This is often the case with families where both spouses work and both carry insurance. If a patient has more than one insurance policy, it is important to find out which policy is primary. This information can usually be determined when you call each company to verify benefits, and they can let you know if they are aware of another policy, and if they are primary or secondary. The primary insurance for an adult is usually the policy they carry themselves, then a spouses insurance is secondary. If your patient is a child, and the insurance is carried by both parents, determining who is primary is a little more difficult. Often times the primary policy is held by the parent with the earliest birthday in a year. It is always important to verify with each insurance company if they are primary in order to determine where to submit claims first.

  • With the advancement of technology in the medical field, many claims are being processed through:

    electronic transmission

    Rationale: Electronic transmission is becoming the fastest and easiest way to submit claims to insurance companies. Electronic transmission allows the claims to be submitted electronically, without having to wait several days for mail processing and delivery. Electronic transmission allows for faster processing of claims, meaning quicker reimbursement for the office.

  • When electronic claims are submitted from a medical facility, they are first sent for processing to a:


    Rationale: Clearinghouses were first devised by Medicare and some insurance companies to pre-screen claims for errors before being submitted to the insurance companies. Each state has different regulations for insurance companies and medical coding, so it is important for a clearinghouse to filter the claims so that errors are returned to the medical facilities to be corrected. The prevents the insurance companies from becoming overwhelmed with claims that have errors, which would be rejected anyway.

  • When an insurance policy has a dollar amount that a patient must meet out of their own pocket before the insurance policy starts to pay, this amount is known as the:


    Rationale: A deductible is a dollar amount that may be included in certain policies, which requires patients to pay a set amount out of their pocket before the insurance company starts to pay. For example, a policy may have a $500 deductible, then the insurance company will pay 80% of covered services. In this case, the patient will have to pay $500 out of their own pocket, plus the remaining 20% not covered by the insurance company. Not all policies have deductibles, so it is important to verify benefits and eligibility for each patient prior to providing services.


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