The processes of medical billing and coding are critical to the healthcare industry, but there are still countless people who wonder what do medical billing and coding do. The job actually requires a substantial blend of medical knowledge, technical skills, and attention to detail, and it helps make sure that healthcare providers are paid accurately and on time for the services they render.

In this post, we’ll be taking a more in-depth look at the job of medical billing and coding, and the processes behind them. We’ll also look at some of the challenges that can pop up from time to time, and how a billing and coding administrator like AMS Solutions is prepared to help your organization scale rapidly.

Understanding The Job Of Medical Billing and Coding

To get a better idea of what medical billing and coding are, you’ll need to understand that both are distinct but closely related functions within the healthcare industry. 

Medical billing involves the process of creating billing claims from provided healthcare services and submitting these to insurance companies for reimbursement. On the other hand, medical coding is the translation of medical diagnoses, procedures, and equipment into universal medical alphanumeric codes. These codes provide a standardized language, which is essential for ensuring accurate billing and record-keeping.

The symbiotic relationship between billing and coding ensures that healthcare providers are reimbursed accurately and promptly, which in turn, supports the financial health of medical establishments. Both functions are critical in maintaining the integrity and efficiency of the healthcare financial ecosystem, easily illustrating why the field is critical.

The Process of Medical Billing

The process of medical billing is pretty meticulous. When a patient visits a healthcare provider, their demographic and insurance information is recorded. Afterward, all of the information is used to generate a bill that delineates all of the services rendered and their costs. This bill is typically then submitted to an insurance company for review and eventual payment. One of the biggest factors in the process is the intricacies, which demand a high degree of accuracy to ensure proper reimbursement.

The Process of Medical Coding

Medical coding, the counterpart to medical billing, is equally vital in the healthcare reimbursement cycle. It entails recording the various diagnoses, procedures, and treatments into codes that are universally recognized. These codes form the basis of billing and ensure that the services provided are accurately represented and reimbursed. The coding process begins with the review of medical documentation from which the relevant codes are derived and then used in the billing process. Accuracy and timeliness in coding are paramount to prevent claim denials and delays in payment.

How AMS Solutions Can Assist

AMS Solutions is one of the most trusted and proficient medical billing and coding administrators by creating a team that is well-versed in the latest coding standards, billing regulations, and insurance requirements, ensuring that your medical establishment remains compliant while optimizing revenue collections. We help alleviate the heavy administrative burden that comes along with having to keep an in-house billing and coding team up to the demands of an ever-changing industry. This way, you’ll be able to focus on what matters most, providing the care you’re known for. 

Partner With AMS Solutions For Hassle-Free Billing and Coding Administration

Understanding medical billing and coding is crucial for maintaining the financial viability of any provider. The intricate and often confusing practices involved in billing and coding are the linchpins of the entire healthcare reimbursement cycle. If you think it may be time for your organization to leave the billing and coding to the professionals and focus on your patients, reach out to AMS Solutions today. 

Those who work in the medical field have a significant amount of responsibility. Not only the doctors and nurses who treat you but also the coding and billing professionals that work behind the scenes on paperwork and medical records. There are countless medical regulations and processes that go into medical coding, and it is crucial that the coding is done properly. We’re going to look at what proper coding is, and exactly what is the importance of knowing proper CPT coding.

What Is A CPT Code?

CPT stands for Current Procedural Technology, and CPT codes create a uniform reporting and coding language that is used to make reporting easier, as well as more efficient and accurate. CPT codes are used for medical billing that is either five digits, or four digits and one letter long, and they indicate medical or administrative management procedures. They are used for claims processing as well as for the creation and modification of medical care review guidelines.

Why Is Proper CPT Coding Important?

Most medical facilities rely on insurance providers for the majority of their funding and revenue. Other sources like healthcare programs contribute as well, but the greatest portion is provided by insurers. Insurance companies make their money by charging policyholders a premium, or fee, that is often paid monthly. Since there are many more people who have insurance than are sick at any one time, it allows the insurers to cover most of the medical expenses or costs for those who hold policies. That said, there is a huge portion of income coming from reimbursements, and a very tiny share coming from patients’ pockets. 

This is why proper CPT coding is so crucial. Every single patient that visits a hospital, care center, or doctor’s office has a file of medical records that need to be kept updated and accurately documented. If the coding and billing are done incorrectly, it can result in the hospital losing significant amounts of money in lost reimbursements. Additionally, accurate and correct billing and coding are needed to ensure that patients are being charged more than they should be and that their respective insurer is charged the correct portion of the costs.

Types Of CPT Codes

There are codes assigned for every potential procedure or service that medical providers can provide or perform. CPT codes even include many unlisted codes for procedures or special services that are not specified in other unique CPT codes. There are three categories of CPT codes created by the AMA, the categories are:

CPT Category I

Category I contains the largest body of standard codes. These are the codes most commonly used by healthcare providers to report frequently used services and procedures.

CPT Category II

Category II contains supplemental codes that are used for performance management and other administrative purposes. There are codes relating to patient history, diagnostics, patient safety, and follow-up procedures.

CPT Category III

CPT Category III contains the most infrequently used CPT codes. It also contains temporary codes that are used to code and bill experimental services, rare procedures, or emerging treatments. 

Understanding CPT Codes And The Importance Of Proper Coding Is Vital For Accurate Recordkeeping

Hopefully, we’ve been able to shed some light on just why proper CPT coding is so essential to the continued operation of healthcare facilities. Without accurate and proper CPT coding, patients would be charged wrong amounts for procedures they never had performed, and the facility would lose out on potentially millions in insurance reimbursements. This can jeopardize not only the health of patients but the longevity of the medical facility as well. 

Are you looking to get into the medical billing career field? Then it’s important that you know what that job will entail based on the type of facility you’re working for. There are clear differences between billing between healthcare and other industries within the medical field. The processing of medical claims across varying facility types and specialties is significantly different. No matter what, medical billers work with one of two types of billing: institutional billing or professional billing. We’re going to look more closely at the differences between facility vs professional claims.

What is Professional Billing?

The staff in a doctor’s office handles many different tasks, from greeting patients and getting them checked in, to scheduling appointments and collecting money. Medical billing is also handled within the office as well. The claims that are generated for the work done by suppliers, physicians, and other non-institutional providers are considered professional billing.

These professional charges are billed on the standard CMS-1500, which is a red ink on white paper claim form that both suppliers and physicians use for claim billing. Not all claims are billed on paper. Most insurance companies, including Medicare and Medicaid, primarily accept electronic claims. When the claims are submitted electronically, it’s the 837-P rather than a CMS-1500.

What is Institutional Billing?

Institutional billing is the billing of claims for work done by institutions. Healthcare facilities like hospitals, nursing homes, and similar facilities that offer inpatient and outpatient services use institutional billing. Not only will it include services performed by the facility, but also the use of various pieces of equipment, the use of laboratory services, radiological imaging services or equipment, and more.

Biggest Differences Between Billing Types

When you compare the basics, it may seem like there isn’t much difference between professional and institutional billing. However, there are some key ways they are separated. The biggest differences between a facility claim vs a professional claim are the duties available as well as the types of forms used. 

Different Forms

Professional billing claims are billed using a CMS-1500 form. The CMS-1500 is a standard form that has red ink on white paper. It is used not just for physicians, but for supplier claim billing as well. If the billing is done electronically, the digital version of the CMS-1500 is the 837-P, with the P standing for professional claims.

Institutional claims are billed using a form called a UB-04. The paper version of this form is also red ink on white paper and is used for the physical billing of institutional charges. The electronic version of the UB-04 is the 837-I, with the I standing for institutional claims.

Roles Addressed

When looking at professional vs facility billing, there are unique claims for different industries and jobs. Facility claims deal with hospital and laboratory services, while professional claims are for physicians that work in medical offices.

Duties and Skills

Regardless of the type of billing, professional vs. facility, medical billing professionals have a crucial responsibility. Medical billers must learn about five distinct areas of billing, including:

1. Understanding how to obtain or use information about each insurance company to submit claims efficiently.
2. Knowing how to perform their duties while maintaining medical confidentiality and avoiding HIPAA violations.
3. Having a working familiarity with the specific billing software that is used will result in massive time savings for training, will reduce errors, and prevent issues and headaches in general.
4. Understanding that coordination of benefits information is vital and that submitting claims in the proper order reduces delays in payment.
5. Understanding that each portion of a medical claim is representative of information collected during the entire time from patient scheduling through treatment.

Prior authorization, or PA, is a requirement for certain medications and treatments. Before you can receive the care you need, your insurance company may need to grant approval first. Sometimes the process is handled before you get to the pharmacy, while other times you may be told you have to wait for your insurance provider to allow you to get the prescription through them. Let’s take a closer look at everything you need to know about prior authorization for medications.

What is Prior Authorization for Medication?

So, what is a prior authorization? Before a physician is able to administer certain medical procedures, devices, or specific medications, they may need to follow the process to get approval from your insurance company. Prior authorization has to be requested before the request for your insurance to cover all or a portion of your treatment. Your physician’s request may even be denied.

Why a Prior Authorization is Required by Insurance

According to health insurance companies, prior authorization is required for some treatments, medications, procedures, and medical devices to keep the cost of healthcare lower.

Medications That Need PA

Prior authorization is a requirement for several different medications. The request may be necessary for a number of reasons, including:

• The medication is expensive (such as rheumatoid arthritis and psoriasis medications)
• There is a cheaper generic version available and the physician is requesting the brand name
• Used to treat conditions that are non-life threatening
• Used at doses higher than normally recommended
• Cosmetic use (such as wrinkle treatments and hair growth)
• Your physician deemed it medically necessary (if this is the case, they need to inform the insurance company that other medications that are covered will not be effective forms of treatment for you)

How to Tell if You Need Prior Authorization

Finding out if your insurance company requires prior authorization is easy. Calling your insurance company and asking them directly is a good way to go. Otherwise, your pharmacy will inform you if prior authorization has been requested by your doctor when you go to fill or pick up the prescription. If it has not been approved, they will charge you the full amount.

How Prior Authorization Works

When your doctor requests a prescription for you, they should contact your insurance for prior authorization. If they did not, however, your pharmacy will contact the doctor to let them know the authorization is required. Once they are aware that approval needs to be requested, your doctor or a member of their staff will reach out to your insurance to get the forms filled out and submitted. This can take a while, depending on your insurance company.

In addition to the paperwork your doctors’ office submits on your behalf, your insurance provider may also require you to fill out some forms as well. You should call them to see if there is anything you need to do on your end before they review and approve your request. Once the insurance company has made its decision, it will contact you, your doctor, or your pharmacy about whether the request was approved or denied.

How Long Does it Take?

In most situations, prior authorization takes a few days to process. The specific time frame depends on what type of medication or procedure your physician has requested, along with the insurance company you have. If you haven’t heard anything by a week after your initial discussion with your doctor, you can contact the pharmacy to see if the request was approved. If your submission was not approved, the next step is to contact your insurance company directly to find out why the request was denied or delayed.

Deductible vs. out-of-pocket is a common question asked by people who are considering health insurance and even by health providers who aren’t often experienced in medical billing terms and services.

The Difference Between Deductible and Out of Pocket in Health Insurance

Out-of-pocket healthcare costs, also known as copayments or coinsurance, are a set amount of money that you’re required to pay for certain services on top of what your insurance covers. With deductibles, there are monthly payments that you make before your insurance starts to cover anything at all.

The deductible is the amount that must be paid by the insured before their insurer will start paying for medical care, and it varies depending on the type of plan chosen. An individual may have to pay up to $2,000 in medical expenses before their insurer starts paying anything at all, while a family might have to pay up to $6,000 in medical expenses before the insurer starts picking up more than 50%.

This means that those with higher deductibles can end up paying a lot out of pocket for health care, which is why many choose to have higher monthly premiums to cover that cost. Some plans may offer lower deductibles for a monthly premium increase.

Other plans with slightly higher premiums may have higher deductibles. The type of plan chosen should be based on each individual’s own needs and preferences, so it is best to consult a financial advisor before choosing a plan.

What is a Deductible?

A deductible is the amount of money that a person must pay out-of-pocket before their insurance company will start paying for a medical service. Deductibles are most common in health insurance plans, but some other types of insurance have them as well.

The purpose of a deductible is to encourage people to be more careful about how they spend their healthcare dollars. For example, if you have a $500 deductible, it will take you five months to reach the point where your insurer starts paying for your care. This means that you’ll spend less on healthcare and be more careful about what services you need and how often you use them.

What is an Out-of-Pocket Maximum?

The out-of-pocket maximum is the most you will pay for your health care services. The out-of-pocket maximum is one of the key features of a health insurance plan. The maximum out-of-pocket amount is the most a person will pay for covered medical expenses. It’s what determines how much you will have to pay for your medical services in a given year.

The out-of-pocket maximum can be different from one plan to another, but it’s usually set at a certain dollar amount. For example, the average in 2018 was $3,000 per family. Unfortunately, not everyone can afford to pay out of pocket.

Why Do Some People Pay Out of Pocket?

The Affordable Care Act (ACA) requires that all Americans have health insurance coverage. However, some people are not able to afford the monthly premiums.

Some people may not be able to afford the monthly premiums because they are living paycheck-to-paycheck and cannot justify spending money on something they don’t need like health insurance. Other people may be eligible for Medicaid but do not know how to enroll or don’t want to take advantage of any government assistance programs that are available.

While some people may be eligible for Medicaid, they will often find that the Medicaid plans have high deductibles and copays which can make it difficult for them to get the care they need when needed.

In addition, many doctors are not accepting new Medicaid patients due to low rates of reimbursement from the federal government. If you need help with figuring out insurance policies and terms for your healthcare practice, please contact us today. You can also visit our detailed FAQ at your convenience.

Contracting with insurance companies can be a tricky business for a healthcare provider, but it doesn’t have to be. With the right information, you can make sure that your company is not only covered but also that you are getting the best possible deal. There are many aspects to consider when contracting with insurance and there are many different types of insurance providers and plans.

Healthcare providers should always contract with Medicare or Medicaid. These two insurance providers are a good option for anyone entering the healthcare field because they give you a lot of leeway in terms of what you’re allowed to charge. In other words, if you don’t have experience, these two insurance providers will give you the opportunity to build it.

What is a Medicare/Medicaid Contract?

A Medicare/Medicaid contract is a legal document that outlines the terms and conditions of a business agreement between a healthcare provider and an individual, organization, or government agency.

The Medicare/Medicaid contract is used to describe the services offered by the healthcare provider. It also includes information about the billing process and how payments will be made. The contract specifies that any medical services provided to patients covered by Medicaid must be at no cost to them. The patient may be asked for co-pays for other services not covered by their insurance plan.

This contract is also used when patients are enrolled in Medicare Part B or D plans. The patient may need to sign this form in order to receive coverage from their insurance company for any medical service provided by the healthcare provider on their behalf, regardless of whether they choose to pay the provider or not. The terms and conditions of the Patient Acknowledgement form are set by the healthcare provider who has contracted with Medicare Part B or D.

What Kind of Health Coverage Does A Medicare/Medicaid Contract Provide?

Medicare is a national health insurance program for people who are aged 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare offers healthcare coverage for hospital stays, doctor visits, medical equipment, and other medical services.

Medicaid is a joint federal and state program that helps pay health care costs for some people with low incomes and limited resources. Medicaid provides health coverage to millions of children, adults, and seniors near or below the poverty line who meet certain eligibility requirements.

How to Get Started with a Medicare/Medicaid Contract?

The Centers for Medicare and Medicaid Services (CMS) has a website that provides information on how to get started with a Medicare contract. This website is the first place to start if you are looking to become a Medicare provider.

There are two ways in which CMS can award contracts: “competitive bidding” and “no-bid.” The competitive bidding process is open to all providers, while the no-bid process is reserved for providers who have been awarded contracts in the past.

In order to participate in competitive bidding, you must submit an application and then wait for CMS approval. If your application is approved, then you will be awarded a contract if the bid amount exceeds your competitors’ bids by 10%.

Let AMS Solutions Get You Contracted with Medicare/Medicaid

AMS Solutions is a billing company in Dallas that specializes in Medicare/Medicaid contracts. We have a team of professional, certified, and licensed coders who are experts in the healthcare industry. We can work with any insurance company and they provide the best customer service. We will take care of all your needs and provide you with the highest payout possible.

Contact us today if you need help with getting your healthcare practice contracted with Medicare or Medicaid. We’ll answer any questions or concerns you may have about working with us. 

When it comes to making money as a healthcare provider, you’re going to need to know how much to charge for the services you provide to your patients. This is a pretty big part of your day-to-day business, so it only makes sense to be educated on how to determine charge amounts as a health care provider.

Why is it Important to Know the Right Charge Amount as a Healthcare Provider?

The pricing of services is one of the most important factors in determining the success of a healthcare business. It is also important for healthcare providers to understand their charge amounts as it has a significant impact on their revenue and profit.

Charge amount: Charge amounts are the fees that a healthcare provider charges to its patients for services rendered. They are usually paid in advance and are not refundable, unlike co-pays.

Pricing strategy: Healthcare providers use different pricing strategies to determine how they want to price their services. They can either use cost-based pricing, value-based pricing, or competitive-based pricing.

Cost-based pricing models: Cost-based pricing is based on the cost incurred by the provider for providing care for a patient and this type of strategy can lead to higher payouts. 

What are the Different Pricing Strategies for Healthcare Providers?

The pricing strategy can be a major factor in the success or failure of a company. Pricing strategies are not only limited to retail stores but also healthcare providers. Healthcare providers use different pricing strategies to either improve the customer experience, increase revenue, or both.

The healthcare industry is one of the most competitive industries which is why many companies have come up with different pricing strategies to stay competitive and make more money. The ways pricing is done in the healthcare industry are:

• Price by service (surgery, medication)
• Price by time (per hour, per day, per procedure)
• Partial price disclosure
• Price by usage

Every healthcare provider is different in how they decide to charge their patients. Some are able to charge what their services are worth and others need to rely on government reimbursement rates which can be lower than the cost of providing the service.

What Happens If You Under or Overcharge Patients?

There are consequences for under- and overcharging patients. Healthcare providers should be aware of these consequences as they learn more about providing health insurance for their patients.

Undercharging patients: If a doctor charges less than what they should, they are essentially giving away their services. This can lead to a shortage of medical professionals and more people going without care. It also leaves doctors with less money to use for their business, which can lead to them closing up shop.

Overcharging patients: Overcharging patients is considered unethical because it is taking advantage of their situation and could cause them financial hardship. This can also lead to a loss of trust from the patient and make them hesitant about returning for future care or even recommending that doctor to others.

How to Determine the Right Charge Amount for Your Services as a Healthcare Provider

There are a few factors that you should take into consideration when determining the right charge amount for your services as a healthcare provider.

• What is the average price of your service in the market?
• How much do you need to cover your expenses?
• What is the average cost for your healthcare services?
• What is the target clientele?

AMS Solutions can help healthcare providers with determining appropriate charge amounts for their practice. Contact us today if you need help with charge amounts, or any other health insurance issue. We can also help with managing your medical practice. 

If you’re an administrator for a healthcare provider or operate your practice, you’ve probably asked yourself, “Should I outsource my medical billing?”, and if so, you’re not alone. In the constantly evolving field of healthcare, countless healthcare professionals grapple with this question every day. Effectively navigating the ocean of complexities of medical billing can be intimidating, overwhelming, and worst of all, time-consuming. So many providers are turning to outsourcing as a solution for their medical billing workload, but is it the right decision for your practice? That’s what we’re going to look at here, so let’s get to it.

Biggest Benefits Of Outsourcing Medical Billing

While each practice will undoubtedly see benefits unique to its operating circumstances and needs, some of the biggest benefits will be seen across most providers. Here’s a look at the most common and prominent benefits nearly every practice can appreciate. 

Time Savings and Efficiency

Without a doubt, one of the biggest benefits of partnering with an outsourced billing provider is the amount of time you can potentially save by outsourcing your medical billing workload. When healthcare providers try to manage billing in-house, the process can be exhaustive, requiring them to balance patient care with tedious administrative tasks.

Outsourcing frees up your in-house team to focus on their core duties. Your front desk team won’t have to juggle billing and appointment booking, and your patient care team won’t need to mix exam room time with 

Access to Expertise and Reduced Errors

Outsourcing your medical billing also gives you access to an army of professionals who specialize in just that. At AMS Solutions, we take pride in being able to deliver our team’s accuracy, up-to-date billing regulations knowledge, and speed, to practices that need help effectively managing their administrative work. This all adds up to fewer errors, quicker payments, and overall smoother daily operations. 

Financial Savings

Another critical point of medical billing outsourcing, and whether or not it’s the right choice for you, is the cost-effectiveness of outsourcing versus keeping the work in-house. Hiring an in-house billing team will, at the very least, require screening candidates, allocating salaries, paying for benefits, conducting onboarding, supplemental or ongoing training as needed, and core infrastructure costs. For small or even medium-sized practices, this can lead to a substantial investment.

In contrast, outsourcing can eliminate virtually all of these challenges or costs for your practice. Your billing team comes already screened, trained, and ready to handle your office’s billing needs. This cuts your overhead down by a considerable margin, makes your costs more predictable, and allows you to shift the cost out of payroll and into a monthly service expense.

Why AMS Is the Leader in Medical Billing Solutions

AMS Solutions is renowned for delivering highly accurate, efficient, and reliable medical billing and collection services. Our robust technology, coupled with our team’s profound expertise, ensures your practice remains compliant while also increasing your revenue. We also stay up-to-date on all billing regulations and industry best practices, so that you don’t have to and so that your business can steer clear of violations and penalties like fines. 

Partner With The Medical Billing Leader For Your Billing & Collections Needs

So, should you outsource your medical billing? The benefits are clear: increased efficiency, access to expertise, cost savings, and more. AMS Solutions places as high of a value on your practice’s success as much as you do, providing superior service to help you focus on what truly matters, and giving your patients an unbeatable level of care. Reach out to AMS today for a free consultation, and allow us to design a customized solution to enhance your practice’s financial health while you concentrate on the rest of your practice.

The healthcare field has never been simple or stationary, but today’s rapidly evolving healthcare landscape is introducing numerous complexities for medical professionals of all types around the world. One of the most crucial aspects of any provider or practice is medical billing and collections, which is a domain that poses a significant challenge for many administrators. If you’re still wondering “What is medical billing outsourcing?” don’t worry, we’re going to get into it. We’ll shed some light on what it is, as well as look at why it’s becoming so popular in recent years. 

What is Medical Billing Outsourcing?

Medical billing outsourcing is the act of delegating your medical billing and collections tasks to an external, third-party agency that specializes in medical billing for various specialties. Agencies like AMS Solutions then take on the responsibility of providing accurate and timely billing, ensuring that your payments are submitted, processed, and received promptly and accurately, and minimizing errors and claim denials. 

Advantages of Medical Billing Outsourcing

Medical billing outsourcing is a strategic move that offers an array of benefits designed to simplify operations and boost your practice’s efficiency and profitability. Each practice will see benefits that are often related to the unique challenges they face, however, there are many advantages that can be seen across practices and specialties. Below are a few of the more significant benefits. 

1. Focus on Core Healthcare Services: One of the key benefits of outsourcing is that it allows your healthcare team to focus on their core job duties of providing care to your patients. Medical billing is a meticulous and time-consuming task that requires a unique set of skills that aren’t usually commonplace in other roles. By outsourcing this aspect of your practice, your team can dedicate their time and energy towards providing top-tier healthcare services, enhancing patient satisfaction.
2. Cost-Efficiency: Investing in state-of-the-art billing software and hiring a dedicated team for in-house billing can bring significant financial burdens to your practice. However, by outsourcing your medical billing, these upfront costs are eliminated and you only pay for the services you need, providing excellent value for your money.
3. Steady Cash Flow: The efficiency and consistency of a dedicated billing agency can ensure a steady cash flow. With an outsourced team working around the clock, there are no delays due to staff shortages, vacations, or unexpected absences. Your billing process continues as long as you’re taking patients, keeping your revenue cycle robust and predictable.
4. Expertise and Compliance: A specialized agency like AMS Solutions brings years of expertise to the table. We stay updated with the constant changes in healthcare regulations, insurance policies, and medical billing codes. Our knowledge and expertise can help prevent costly errors, ensuring compliance and saving your practice significant amounts of money.
5. Access to Advanced Technology: Finally, when you outsource your medical billing, you get access to advanced technology without the need to purchase and maintain it. Agencies like AMS Solutions utilize cutting-edge software to ensure accuracy, and efficiency, and to provide detailed reports for your convenience.

Partner With A Medical Billing Leader To Future-Proof Your Practice

AMS Solutions is a leading provider of medical billing outsourcing services that encompass everything from new patient registration, insurance validation, and verification, to claim submission and even follow-ups to aging claims. Our team is expertly trained to handle any billing scenario so that you and your practice always receive payments due in a timely and efficient manner.
If you think you and your practice may be ready to take the next step in optimizing your billing process, AMS Solutions may be the best choice for your business. Reach out today for more information or to discuss how we can help your practice meet its billing needs.

Healthcare coding and billing can be incredibly complex, and understanding the intricacies can be challenging. One of these challenging aspects that many people wonder about is credentialing in medical billing. In the simplest terms, credentialing is a critical process that every medical practitioner must go through to validate their professional qualifications, and thus affirm their eligibility to practice medicine or provide other healthcare services. We’re going to look at what credentialing in medical billing is, and why it’s so important. 

What Is Credentialing In Medical Billing?

The primary question, what is credentialing in medical billing, will typically arise because of the profound impact it can have on a healthcare provider’s qualifications and their subsequent ability to run their operations smoothly and ensure a constant stream of revenue. Credentialing in medical billing is the method by which the insurance company evaluates and approves healthcare providers to accept their insurance for patient treatment. This process will generally involve a deep dive into the provider’s qualifications, education, residency, licenses, specialty equipment, and overall performance history.

Importance of Credentialing

Credentialing isn’t just a bureaucratic necessity, it’s a critical step in establishing trust and a positive reputation in the healthcare industry. Once credentialed, healthcare providers become part of an insurance company’s often extensive network. This affiliation also allows patients who are insured with that company to receive services from the provider, which broadens the provider’s patient base considerably. A broader patient base means more referrals and dramatic increases in revenue.

What is Provider Credentialing in Healthcare?

While the question of what is credentialing in medical billing is significant, it’s essential to understand the relative concept of what is provider credentialing in healthcare. Provider credentialing in healthcare is fundamentally the same process, although it extends far beyond the insurance company and encompasses hospitals, clinics, and other healthcare facilities. Extending the credentialing validation increases credibility and ensures that patients receive care from qualified and skilled providers that meet the criteria.

Credentialing is a Rigorous Process

As you dig deeper into what is credentialing in medical billing, you’ll see it’s a highly rigorous process that has several distinct stages. It starts with gathering extensive information about the provider, followed by a thorough investigation of the details collected. Insurance companies then evaluate the data that’s been verified to assess whether the provider is competent and reliable enough to receive the credentialing. This due diligence is critical, as it directly impacts the level of care the patients receive, as well as the integrity of the healthcare provider’s overall coding and billing practices. Trust AMS Solutions to navigate this rigorous process seamlessly and professionally, saving you both valuable time and resources.

How AMS Solutions Can Help?

Credentialing in medical billing is a time-intensive, meticulous process that requires extensive paperwork and verification procedures. This is where AMS Solutions steps in to lighten your load and streamline your entire operation. Our entire team is made up of specialists in medical billing management, as well as collections, who can simplify everything for you and ensure an error-free and efficient experience. 

Your Trusted Partner for Medical Billing

By now, it should be clear what credentialing in medical billing is, as well as why it’s so vital. It serves as a testament to a healthcare provider’s qualifications and helps to build trust between patients, providers, and insurers. Navigating the credentialing process can be intimidating though, so consider letting AMS Solutions help you simplify the entire process and manage your medical billing and collection needs. Our understanding of the process and extensive healthcare industry experience means you only receive the best service. Contact AMS Solutions today to learn more or to start the switch to managed billing and collections.