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Understanding The Medical Billing Process

Keys To Understanding The Medical Billing Process

Why you may receive several bills for one procedure

Many steps are taken between the time you receive medical services and when you get your bill. The medical billing process requires the coordinated efforts of your health care provider, insurance organization(s) and the billing office/agency. In some cases, several months may pass before all parties coordinate payment and you receive a statement for the unpaid balance unless prohibited by your health plan or other regulations. The information below can help you better understand this complicated process.

The medical billing process

These are the typical steps taken between the time you receive medical services and you receive your bill: 

  1. When you go to your hospital or health care provider’s office for a medical procedure, the admitting clerk or office clerk gathers information such as: your name, address, date of birth, social security number; and the name of the person responsible for paying for services (the guarantor), his/her address and employer, his/her insurance organization(s) and insurance coverage information needed for billing the appropriate insurance organization(s). (If the health care provider uses a billing agency for billing and collection, this information is shared with the agency.) 
  2. After the medical procedure is performed, the billing office files a claim with your primary insurance organization for services. (In many cases, payment is sent directly to your health care provider, not you.) 
  3. If your insurance organization won’t pay because there is a problem with information provided, the billing office tries to collect correct information and re-files the claim. 
  4. When payment is received, if there is supplemental insurance coverage (if you have secondary insurance coverage), the billing office files a claim with your secondary insurance organization for the part your primary insurance organization didn’t pay.
  5. When all insurance has been processed, you’re billed for any remaining unpaid balance unless prohibited by your health plan or other regulations. You receive a statement. 
  6. If you don’t pay the balance on your statement, the billing office tries several times to collect. If you still don’t pay, a collection agency may be asked to take over to collect the money you owe. (Note: If for instance, you lost your job and can’t pay all of it now, call the billing office immediately to set up a payment plan to pay just a little bit each month — and make sure that they put that on your file. For details about how not paying could affect your credit report rating, go to Frequently Asked Questions.) 

Why you may receive several bills for one procedure

You may receive one bill or more than one for a single medical procedure. How you’re billed depends upon how your health care provider is set up for billing professional and technical services. For instance, when an x-ray is taken, the professional part involves the professional services of a radiologist (interpreting the image to assist in determining diagnosis and treatment). The technical service consists of use of the exam room, film, equipment creating the image and personnel using equipment and film. Sometimes you receive one bill that includes both professional and technical services. Sometimes you receive one bill for professional services and another for technical services. Here are two examples that illustrate this — both for an x-ray.

Separate bills for the professional and technical parts of a procedure Your x-ray was taken at the hospital, where health care providers bill for their professional services separately from the hospital. So for this same procedure, you receive one bill for technical services from the hospital — and one for professional services from the radiologist. (If you have a procedure performed in a hospital that requires services from a radiologist, a surgeon, a pathologist and an anesthesiologist, you receive a separate bill from each professional plus another from the hospital.)

A combined bill for the professional and technical parts of a procedure – Your x-ray is taken in your health care provider’s office and he/she owns the equipment used. Then, billing is combined for the technical and professional parts. You receive only one bill for both parts.

For more information about various parts of the medical billing process, go to Frequently Asked Questions. Our Medical Billing Glossary explains medical billing terms. A Sample Statement shows what various parts of your statement mean. And Account Information gives information about your account with your health care provider and shows how your health care provider, insurance organization(s) and the billing office or agency worked together in the billing process for each service provided.