When considering outsourced medical billing services, you have multiple options. Depending on your situation, you might want to outsource medical billing on the front end or back end. And while there are benefits to both, your leadership should consider them separately when looking for the best medical billing company and new medical billing services.
Understanding Front-end vs. Back-end Medical Billing
Front-end and back-end medical billing are two phases of the medical billing process. When considering outsourced medical billing services, you should look at them as two distinct parts [1].
Front-End Medical Billing Services
Front-end billing is the pre-service phase before the patient sees a doctor or clinician. It includes their interactions with front-office staff and patient-facing billing activities. Any staff or outsourcing company should have a deep understanding of your payer mix and the plans accepted to support verification of insurance eligibility. They should also understand filing deadlines and how pre-authorization works for each payer.
The pre-registration and registration phases start when a patient makes contact to schedule an appointment or register at a hospital. This involves staff pulling the patient’s insurance and demographic information. Additionally, the patient can complete a registration form when they arrive on site. It is advantageous to maintain standard operating procedures at this phase. It allows you to avoid data capture errors and maintain accurate patient data in the eligibility and benefits phase. Many providers outsource this phase when they’ve struggled to maintain procedures or don’t have the resources to keep up with pre-registration and registration needs.
Verifying insurance eligibility is also critical at the front-end billing phase. If eligibility is incorrect, a provider risks not receiving payment for services. Front-office staff or an outsourcing partner are tasked with confirming that the patient’s health plan covers scheduled services. This phase can happen via phone or through an insurer’s electronic eligibility verification tool, making it ideal for outsourcing. These tools check eligibility effective dates, copay and deductible, patient coinsurance, and plan benefits. This is also the phase at which pre-authorization is obtained.
Once benefit information is determined, staff now know the patient’s responsibility. This is an opportunity to collect deductible, copay, coinsurance, and even the full balance due and can happen during check-in or checkout. This is a critical focus in positive revenue cycle outcomes, since collecting on the front-end eliminates the resource drain of follow-up, bad debt collections, and write-offs.
Next, an encounter form (also known as a fee ticket or super-bill) is generated for the encounter. This form includes patient demographics and common services along with medical codes. It is used to relay information about the type and number of services that the patient has received. After the encounter, the provider will select the appropriate boxes and then sign the form to verify that the selected services were performed and are ready to bill. This process is often electronic for providers that use an EHR or practice management system.
Finally, at checkout, staff makes a follow-up appointment and checks that the provider properly completed the encounter form. This phase is another opportunity for point of service collections. After check out, coders pull the medical records and convert billable information into medical codes.
Back-end Medical Billing Service
The back-end side of medical billing involves billers communicating with physicians to pull more information about a patient encounter or clarify a diagnosis. This process requires that the biller understand CPT®, HCPCS Level II, and ICD-10 codes.
The back end medical billing service process starts with charge entry and claim generation. The encounter form is sent to the charge entry staff, including the services and procedures that were performed and the reason why. Charge entry staff is responsible for entering charges into their practice management system and documenting payment made by the patient at the point of service. After this process is done, claim generation begins. It involves compiling charges, revenue codes, and other codes. Information is pulled from the super-bill, allowing medical billers to begin preparation of the claim. The super-bill is itemized and includes the date of service and other essential provider information. After it’s pulled, the information is translated to a claim and then forwarded to third-party payers to begin reimbursement. This is also when claim scrubbing takes place, a process that makes sure diagnosis, procedure, and modifier codes are included and accurate. This usually happens via claims being run through claim scrubbing software, though some providers send their claims to clearing houses instead and sometimes in addition to the scrubbing process. These companies review, edit, and format claims, getting them ready to go to payers. This process is usually performed electronically through software that meets HIPAA and electronic filing standards.
Benefits of Outsourced Medical Billing Services
When considering outsourced medical billing services, prioritize companies that offer both front and back-end services. These vendors will have a more holistic view of your revenue cycle and will allow you to start with one end and then graduate to the other in your outsourcing strategy. We offer both at 3Gen Consulting and invite you to contact us today to explore your options in front- and back-end medical billing outsourcing.
References
[1] AAPC, “What is medical billing?,” 4 March 2022. Available: https://www.aapc.com/resources/what-is-medical-billing.
