An A-Z Guide on Billing System in Hospital

Challenges in Hospital Billing

Medical billing can be quite taxing, and hospitals often struggle due to many roadblocks. According to some reports, nearly 50% of primary care centers are tired of billing procedure updates and making changes. Despite these issues, several providers are still reluctant to adopt robust hospital billing software. Here are some of the challenges in medical billing that can be resolved effectively using billing software.

1. Multiple Claims Issues

Filing multiple claims can be exhausting for providers and hospital resources. This often leads to delays in claims processing, errors, and even difficulty tracking the status of individual claims. Multiple claims mean a large volume of data, and the inability to manage such a huge amount of claims can negatively impact the financial status of hospitals. Besides, filing multiple claims means handling different payers with their interests, deadlines, and processes. And this complicates the billing workflow process and even the work pressure on the staff.

2. Growing Demands for Information

Since the Covid pandemic, several insurance companies have increased their demand for patient information. Payers have updated their standards; they now want more detailed information about a patient’s condition and treatment procedures. With such increased demand for information, billers and coders are bound to slow down the claims processes. Moreover, they predict a higher risk of errors and inaccuracies. And all these will ultimately impact the claims process.

3. Errors in Coding

While Computer Assisted Coding is quite a trend, these days human coders still hold a significant population in the current healthcare ecosystem. Human coders mean higher chances of errors such as typos that will lead to claims denials and loss of payment.

4. Quality Training Requirements

In medical billing and coding processes, the staff requires quality training to understand multiple systems that function with billing. The staff must know systems like EHR and EMR to efficiently access patient information. Besides, billers and coders must renew their credentials from time to time. And the renewing process will also help them stay up-to-date about the new regulations.

5. Laws Related to Confidentiality

Privacy in medical billing is of utmost priority. So, laws and regulations related to maintaining the confidentiality of billing, such as HIPAA, must be followed strictly. However, these laws are subjected to frequent updates and changes, which are often difficult to track. This can negatively impact the claims process and cause additional losses, too, due to penalties.

6. Technological Advancements

The emergence of new technology in billing and coding, such as CAC, can scan clinical records and determine the codes. Hospitals tend to keep programmers as staff to observe the new technology CAC’s functionality and accuracy. This is time-consuming for staff to acquire such a keen eye for observing accuracies.

Process of Medical Billing System

The medical billing system involves several steps to ensure medical professionals are reimbursed for their services.These includes-

1. Patient Registration: The first step is patient registration, which involves collecting basic demographic information such as name, birth date, and reason for a visit. Medical billers also collect and verify insurance information, which is then used to create a patient file for the billing process in healthcare. 

2. Confirming Financial Responsibility: The second step is determining financial responsibility for the visit. This involves reviewing the patient’s insurance details to determine which procedures and services are covered. If any procedures or services are not covered, the patient is informed of their financial responsibility.

3. Patient Check-In and Check-Out: The patient checks in at a healthcare facility and fills out forms to collect personal and insurance information. They provide documents for identification, like insurance cards and driver’s licenses. After their visit, their medical report is sent to a medical coder, who analyzes the documentation to create a diagnosis and billable procedure code. A superbill is generated, and co-payments are collected, usually billed at the time of service.

4. Prepare Claims: The preparation of a medical claim is the next crucial step in the billing process in healthcare, where a medical biller prepares a claim based on the patient’s and provider’s details, the services offered, and the expected payer’s cost. The biller ensures that the claim meets the basic requirements and standards of billing compliance, as per the guidelines of the Health Insurance Portability and Accountability Act (HIPAA).

5. Claims Submission: Medical billers submit their claims to a payer or a clearinghouse, which takes away the burden of filing and reformatting claims according to insurance payers’ requirements. Clearinghouses receive and reformat claim information, ensuring it meets compliance standards and is submitted in the appropriate form. They also assist in ensuring claims are submitted in the correct format for payers.

6. Adjudication: During the adjudication process, the insurance payer evaluates and reviews a claim to determine its compliance. If accepted, the payer pays, while rejected claims require correction and reimbursement. Denied claims are refused by the insurance payer. If accepted, the payer determines the reimbursement amount and provides a medical biller with a report detailing the coverage and any explanations for denied claims.

7. Generate Patient Statement: The next step is to generate a patient statement detailing the services covered by their insurance provider and the portion of the cost they are now required to pay. Once the biller receives the payer’s report, they create the bill for the procedure or procedures the patient received. The remaining amount is passed to the patient. In some cases, a biller may include an Explanation of Benefits (EOB) to explain the coverage of certain procedures.

8. Handle Collections: The final phase is ensuring those bills get paid. Billers are responsible for sending accurate medical bills and following up with delinquent patients. Once paid, the information is stored in the patient’s file. If a patient is delinquent, the biller ensures proper reimbursement for services. This may involve direct contact, follow-up bills, or enlisting a collection agency. Each provider has specific guidelines for bill payment, notifications, and collections, so it’s essential to follow their billing standards.

Types of Billing Systems in Hospitals

Hospital billing systems come in various configurations to meet a hospital’s diverse requirements. There are three types of billing systems: open, closed, and isolated.  

A. Open Systems: Open systems involve external entities or third-party vendors in the billing process, allowing hospitals to leverage specialized expertise for specific billing functions. They offer flexibility and optimize efficiency in the hospital billing workflow. Open medical billing apps integrate with EHRs, enabling transparent patient status access and information sharing across various medical departments.

B. Closed Systems: Closed systems manage the entire billing process internally, including patient registration, coding, claim submissions, and follow-up with insurance companies. They provide direct control over every aspect of billing but may require substantial in-house resources and expertise. A closed billing system restricts information access to a specific practitioner, digitalizing patients’ paper charts and preventing physicians from sharing billing information with other practitioners. 

C. Isolated Systems: Isolated systems are used by smaller healthcare facilities or specialty clinics, creating a focused and simplified system. Although they may lack the comprehensive features of larger, integrated systems, they are a practical choice for institutions with specific billing needs. This system is exclusive to patients, who track their visits and bills, preventing physicians, nurses, and healthcare institutions from accessing patient-stored information.

Key Requirements to Successfully Implement Hospital Billing Software in 2024

In today’s practice management, big issues are revenue losses, claims denials, billing, and coding errors. However, healthcare automation solutions are transforming these problems in the medical practice. Similarly, medical billing software also changes billing dynamics in the hospital management system. A successful hospital medical billing software must have a few essential requirements.

1. Patients’ Pre-Registration and Check-in

 A hospital medical billing process must get the patients onboard first. Pre-registration is the first step to initiating the medical billing process. Patients’ information is essential for the appointment and further payments. Moreover, hospital management needs to check patients’ eligibility for insurance and other Medicaid benefits. So, patient pre-registration is instrumental in the billing process and patient satisfaction. Besides, the medical billing system must include pins for patient check-in forms, eligibility options, medical benefits, and patient payment software history. Moreover, providers trying to implement billing systems in hospitals can opt for customized medical billing software as needed. Healthcare Providers can also integrate electronic health records with the hospital billing software to manage patient history and other details.

2. Verify Insurance

Healthcare providers must ensure the billing system software in hospitals verifies patients’ insurance. Every time the patient books an appointment in the hospital, the insurance needs verification. Checking the insurance status is important for easy and fast processing of claims or reimbursements. So, providers must double-check before initiating the billing process. Also, patients with medical benefits need verification of their status and insurance coverage. It’s just to ensure that all insurance and medical benefits information and coverage are up-to-date. Providers can boost their verification process through an integrated healthcare billing process.

3. Medical Transcription

Medical transcription is required in the hospital billing software after the patient-clinician consultation. It’s the work of qualified professionals to listen to and analyze the diagnostic documents to prepare a medical script. Eventually, this medical script is used for further consultation and medical billing. So, clinicians and medical transcription professionals need to ensure it is error-free to facilitate faster bill processing. Providers can also resort to healthcare analytics solutions to improve the medical script.

4. Medical Coding

Every medical bill must follow specific medical information codes. Professional coders use different codes to define the reason for visits, type of disease, potential treatment plan, and place of service delivery. All this information in specific codes makes it easier to understand the bill.

5. Claims Management

The billing software for hospitals must address the requirement of claims management. Organizing, filing, and processing medical claims of patients’ care episodes. And providers can only simplify this process by automating claims management. Moreover, providers can even use effective medical informatics or cloud computing solutions to manage claims denials. 

6. Billing Collection

It’s a long process, from appointment scheduling to payment receiving. Medical billing and collection is an essential requirement in medical billing solutions. Providers need to send out invoices to insurance and patients for payments for this. It must include functionalities such as patient statements, bill generations, soft collection letters, bill recording, automated billing, and more.  

7. Patient Information

Healthcare billing software requires accurate and centralized access to patient information. Patients and insurance providers having patient information will impact the billing process in hospital. Moreover, accessing patient information through a centralized interface can also be used for population health management and patient engagement systems. Further, integrating EHR with the medical billing system will also optimize medical records management. 

8. Workflow Management

Today’s medical billing software must meet workflow management requirements. With loads of administrative billing and coding till payment processing, providers have an array of tasks. This workflow management function in the hospital billing solutions will speed up the process with accuracy and optimize staff workflow. Moreover, providers need to ensure proper electronic data exchange in workflow management to maintain accuracy. 

9. Compliance

Of all the requirements, a billing system in hospitals must have regulatory compliance. It assures the users of the safety and security of the patient information. The data in the medical billing system needs security, and HIPAA compliance is the best way to protect the software and patient data.

10. Payment Collection

Payment collection is the last and most important function of medical billing management solution. The complete billing process ends with insurance and individuals paying the claim. Either traditional payment or electronic transfer is the two possible payment processes. However, bulk payment must accompany an EOB, and providers need to update it in the hospital EHR system.

The Future of Technology in Hospital Billing 

In the coming years, technological innovation and healthcare administration are expected to revolutionize hospital billing services. Artificial intelligence and machine learning will enhance predictive analytics, optimize processes, and identify potential issues. Additionally, blockchain technology will revolutionize data security and transparency in healthcare payment transactions, ensuring the privacy of sensitive financial information. Interoperability will lead to improved communication between healthcare systems, fostering seamless data exchange for efficient billing practices. In medical billing software, patient engagement tools will help create a transparent, patient-friendly billing experience with features like personalized portals, real-time updates, and simplified payment options, empowering patients to manage their finances actively.

Custom Vs. Ready-Made Solutions: What To Choose?

Ready-made medical billing apps can rapidly automate invoicing in medical establishments. Hospitals and clinics use them to support revenue cycle management. These solutions are often offered as licensed software or through recurring subscriptions. On the other hand, custom-made healthcare billing software is developed from scratch and tailored to each medical establishment’s unique requirements, billing practices, and existing healthcare systems. 

If you are starting your practice with a low budget, you can benefit from a ready-made solution. You should keep in mind that medical establishments often outgrow generic software as they cannot be customized to meet changing and complex business requirements. Alternatively, custom medical billing solutions offer flexibility, customization, and integration for larger practices, allowing complete control over data security, user experience, and billing workflow. Despite the initial investment, custom solutions offer a better return on investment, especially for medical establishments with multiple departments or physical premises.

Conclusion

Billing management systems in hospitals have transformed over the last few decades. From a manual paper-based medical billing and coding process to complete automation, providers benefit from the billing system in hospital. Moreover, if you are willing to invest in a hospital billing system, choosing a vendor that can customize the billing software per your needs is wise. You incorporate all basic requirements and functionalities to boost the providers’ billing and revenue cycle process.