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.[2] Because the U.S. has a mix of government-sponsored and private healthcare, health insurance companies - otherwise known as payors - are the primary entity to which claims are billed for physician reimbursement.[3] The process begins when a physician documents a patient's visit, including the diagnoses, treatments, and prescribed medications or recommended procedures.[4] This information is translated into standardized codes through medical coding, using the appropriate coding systems such as ICD-10-CM and Current Procedural Terminology (CPT). A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors.[2]
Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines.[4] The payor returns the claim back to the medical biller and the biller evaluates how much of the bill the patient owes, after insurance is taken out. If the claim is approved, the payor processes payment, either reimbursing the physician directly or the patient.[5] Claims that are denied or underpaid may require follow-up, appeals, or adjustments by the medical billing department.[5]
Accurate medical billing demands proficiency in coding and billing standards, a thorough understanding of insurance policies, and attention to detail to ensure timely and accurate reimbursement. While certification is not legally required to become a medical biller, professional credentials such as the Certified Medical Reimbursement Specialist (CMRS), Registered Health Information Administrator (RHIA), or Certified Professional Biller (CPB) can enhance employment prospects.[6] Training programs, ranging from certificates to associate degrees, are offered at many community colleges, and advanced roles may require cross-training in medical coding, auditing, or healthcare information management.
Medical billing practices vary across states and healthcare settings, influenced by federal regulations, state laws, and payor-specific requirements. Despite these variations, the fundamental goal remains consistent: to streamline the financial transactions between physicians and payors, ensuring access to care and financial sustainability for physicians.