How it works on the inside - billing inside hospitals and clinics
Years in this field. There are not enough words to explain my anger at the system. The primary point is that it is broken, everyone on the "inside" has known for ages, COVID was the death knell.
I could make post after post on why it is broken but I think it is easier to explain how it is intended to work for the first one. Because I will be real with you people on the inside that WORK ON THESE TEAMS do not even fully get it.
This example is for a hospital (think ortho, cancer centers, surgery, etc) - clinics, like your primary care clinic use a very simplified version of this.
The first people you usually speak to are called "Patient Registrars" the team is usually called PAS (Patient Access Services). These are the front line staff that get you scheduled, take your insurance, get your authorizations. It is the doctor that SENDS the referral who is responsible for getting your initial authorization. Usually this is for a consult. The authorizations after are done by the folks above.
Side bar - what is an authorization? it is a request by your doctor for something you need that the payor/insurance company agrees that they will pay for. These can be for a one time service like a MRI, or something that is based upon time/dosage - like chemo. The latter must have re-auths done by the team mentioned above.
Lets say this all goes according to plan, which it does for the most part. What happens after you get your first visit?
The doctor goes into their medical record (sometimes called an ELECTRONIC MEDICAL/HEALTH RECORD -EMR/EHR; these used to not be electronic and be on paper, some facilities are still on paper. The medical field is the last bastion of faxing in this nation) and documents what was found/discussed - their diagnosis, prescriptions, next steps like treatment or routine meetings etc.
That information (regardless of format) flows to a team called the Medical Records Team. They do a QA, make sure the registration folks didn't miss any forms, the nursing staff got all the stuff they need and then ship it over to coding/charging.
Now this next step does involve traditionally 2 teams. It can deviate by facility, some are merged, some are not. Lets talk about a bigggg ass facility with all the proper teams and staff.
Charging - this is a sub team of either 3 different departments: Health Information Management (HIM), Patient Financial Services (PFS), or Revenue Integrity (RI). Regardless these folks sit down, review what the doctor wrote and generate charge codes based upon it. There is a dictionary (several truly) in every hospital with every price for every service. These prices are set based upon a few factors but I will delve into that in another post called Charge Master or CDM.
From there it goes to coding. Coding reviews these records and documents in extreme depth. They assign codes (which are dictated by CMS - the gov office that oversees Medicare) that is digestible to insurance companies. If anything looks off they send it back to the correct team to fix - most of the time their communication is directly with the doctors themselves. These communications are part of your EHR and available to you if you request them.
Once coding is done then it goes to billing/PFS. PFS then does another QA (sometimes this is done via the tools not a human) and a claiml is generated and sent to a clearing house.
A clearing house is not a bank - it is like a transit center for facilities and insurance companies and their banks (Change Healthcare is owned by UHC and is the biggest clearinghouse in the nation). So a claim goes to the clearing house, it is scrubbed AGAIN for errors, and then sent to the respective insurance company. The insurance company then goes through a fun little circus which is again another post. Eventually they tell the facility (via the clearing house) the claim is either denied, partially denied or fully approved and sends the $ to the clearing house. Sometimes that money goes directly to the bank of the facility ymmv. Regardless the PFS team goes and pulls this data from the clearing house and updates the patients record accordingly.
They will then begin the denial process of fighting the insurance companies. There are hundreds of denial types, but generally they are called technical denials or medical necessity denials. Another post.
This usually takes months of arguing, sending information, resubmitting, rinse and repeat. At the very very end of it the patient (only if the insurance agrees) gets a bill. From THERE the patients will then reconnect with the hospital billing team and maybe the financial assistance team.
This lovely system is called the REVENUE CYCLE. It is sometimes a division, sometimes its left as standalone departments, each functioning on their own. Sometimes the facility is small enough there is only 1 person responsible for a function instead of teams.
I will make a few more posts - specifically break downs. Reach out if you want me to dive into anything specific.
