Medical billing

Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.^[1]

This bill is called a claim. Because the U.S. has a private healthcare system, health insurers are the primary entity to which claims are billed for physician reimbursement. Once the services are provided, the healthcare provider creates a detailed record of the patient's visit, including the diagnoses, procedures performed, and any medications prescribed. This information is translated into standardized codes using the appropriate coding system, such as ICD-10-CM or Current Procedural Terminology codes—this part of the process is known as medical coding. These coded records are submitted by medical billing to the health insurance company or the payer, along with the patient's demographic and insurance information. Most insurance companies use a similar process, whether they are private companies or government sponsored programs. The insurance company reviews the claim, verifying the medical necessity and coverage eligibility based on the patient's insurance plan. If the claim is approved, the insurance company processes the payment, either directly to the healthcare provider or as a reimbursement to the patient. The healthcare provider may need to following up on and appealing claims.

The medical billing process requires accuracy, knowledge of medical coding guidelines, and familiarity with insurance policies to ensure timely and accurate reimbursement for healthcare services rendered. Medical billers are encouraged,^{[by whom?]} but not required by law, to become certified by taking an exam such as the CMRS Exam, RHIA Exam, CPB Exam^[2] and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the United States offer certificates, or even associate degrees, in the field. Those seeking advancement may be cross-trained in medical coding or transcription or auditing, and may earn a bachelor's or graduate degree in medical information science and technology.

It is not required to have a certification to learn billing, though it may help with employment prospects, and billing practices vary from state to state.