Medical Billing FAQ
Maximize Reimbursements, Reduce Claim Denials, and Streamline Billing Operations with TriumpHealth’s RCM Expertise
1. What is medical billing and how does it fit into Revenue Cycle Management (RCM)?
Medical billing is the process of translating clinical encounters into claims, submitting them to payers, posting payments/ERAs, and managing denials or patient balances. It is one phase of the broader Revenue Cycle Management (RCM), which spans from patient registration and eligibility verification to final zero-balance collections.
2. Which codes are used in medical billing (CPT, HCPCS, ICD-10)?
- CPT®/HCPCS Level I & II codes describe procedures, services, and supplies.
- HCPCS Level II covers items like DME, injections, and supplies.
- ICD-10-CM codes capture the patient’s diagnoses and medical necessity. Accurate code selection and modifier usage are critical to clean claims and reimbursement.
3. CMS-1500 vs UB-04: Which claim form should I use?
- CMS-1500 (837P) for professional services (physicians, NPs, therapists, DME suppliers, etc.).
- UB-04 (837I) for institutional/facility claims (hospitals, ASCs, FQHCs, home health agencies, etc.). Some organizations submit both, depending on their service lines.
4. How long does it take to get paid after submitting a claim?
Generally, Medicare and many commercial payers reimburse within 14–30 days of a clean electronic claim. Paper claims, out-of-network plans, or claims with medical review/attachments can extend payment timelines.
5. What are the most common reasons claims are denied?
Top denial drivers include:
- Incorrect or missing patient eligibility/insurance info
- Coding errors (DX/CPT mismatch, wrong modifiers)
- Lack of prior authorization or referral
- Incomplete documentation or medical necessity not supported
- Bundling denials
- Untimely filing
6. How can we reduce denials and rework?
- Verify eligibility/benefits before every visit
- Use pre-authorization checklists for services that typically require approval
- Conduct front-end coding audits and use claim-scrubbing tools
- Track denial trends and update workflows/payer rules accordingly
- Provide coder/biller continuing education on payer updates
7. What KPIs should we track to measure billing performance?
Key metrics include:
- Days in A/R (overall and by payer/aging bucket)
- Clean Claim Rate and First-Pass Resolution Rate
- Denial Rate and Denial Recovery Rate
- Average Reimbursement per Encounter/Procedure
- Net Collection Rate (NCR) and Bad Debt %
8. What is the difference between a write-off and an adjustment?
- Contractual write-offs are the difference between charges and the allowed amount based on payer contracts.
- Adjustments can be additional changes (e.g., courtesy discounts, small balance write-offs). Both should be tracked separately to understand true revenue leakage.
9. Do I need prior authorization for every procedure?
No, but many high-cost diagnostics, surgeries, DME, and specialty drugs require it. Each payer publishes lists of services needing authorization. Missing auth can result in full claim denial.
10. How does patient responsibility (copays, coinsurance, deductibles) impact collections?
Patient balances keep growing with high-deductible plans. Best practices:
- Collect copays and known amounts upfront
- Provide transparent financial counseling and estimates
- Offer payment plans and online payment portals
- Automate statements and reminders
11. Why enroll in ERA/EFT?
Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) help streamline your billing, including:
- Faster, automated posting of payments and adjustments
- Reduced manual errors and mailing delays
- Easier reconciliation between bank deposits and payer remits
12. How often should we audit our coding and billing?
Perform internal audits quarterly and external audits annually (or after major coding/POS changes). Focus on high-dollar, high-risk specialties and services. Use findings to train staff and refine policies.
13. What software or tools are essential for efficient medical billing?
- Practice Management (PM) or billing platform with claim scrubbing
- Clearinghouse for secure EDI transmission and rejection management
- Eligibility/benefit verification tools
- Denial analytics dashboards/KPI reports
- Secure document management & task tracking for follow-ups
14. Is medical billing different for DME, FQHCs, ASCs, or mental health providers?
Yes. Each has unique requirements, e.g., DME billing uses HCPCS and modifiers; FQHCs use PPS/G codes on UB-04; ASCs follow CMS ASC Fee Schedule and implant pass-through rules; mental/behavioral health may have visit limits and telehealth rules. Tailor workflows to each service line.
15. How does outsourcing billing to a specialist like TriumpHealth help?
- Access to experienced coders, billers, and AR specialists across 40+ platforms
- Lower denial rates (our average is ~5%) and faster collections
- Centralized reporting and compliance oversight
- Scalability for growth without hiring/training overhead
16. What is included in TriumpHealth medical billing services?
Our revenue cycle management service includes handling all your outbound claims and inbound remittance and payments, both electronic and on paper. We proactively address claim appeals and manage denials on your behalf. And by continually expanding our billing services, we’re taking administrative tasks off your hands. We make your claims our business, so your business can move faster.
17. How does TriumpHealth billing team handle non-payments from an insurance carrier?
We must first determine if the denial, whether in part or in full, is valid. If the denial is not valid, we will request the payer to reprocess the claim. For instance, if the denial is for diagnosis or modifier we will correct and rebill the claim. If the denial is for medical necessity we will send the medical records, and appeal if needed. Depending on the payer, we may file multiple appeals, including administrative appeal, and follow-up till the claim is paid or we receive a decision in writing otherwise.
18. How often will our patients receive statements?
The patients will receive statements for any balance due, once a payment has been received by their insurance carrier. Depending on your workflow, the patient statements are normally sent once a month.
19. How do I get started with TriumpHealth’s medical billing services?
Step 1: Discovery Call – share your specialties, volumes, platforms, and pain points
Step 2: Workflow & Data Review – we assess current AR, denials, and systems
Step 3: Proposal & Onboarding Plan – we define scope, SLAs, pricing, and KPIs
Step 4: Go-Live & Reporting – seamless transition with weekly status reports and ongoing optimization
Ready to improve your billing performance, schedule a free consultation. You can always contact us via Email [email protected] or call (888) 747-3836 x0.
Learn more: TriumpHealth Medical Billing Services
Disclaimer:
The content provided by TriumpHealth is for informational purposes only and does not constitute legal, medical, or financial advice. Regulations and payer requirements may change; please consult a qualified professional for guidance specific to your situation. Click here to review our full legal disclaimer.
Maximize Your Revenue. With Expert RCM Services
Schedule a consultation today to achieve financial success and regulatory compliance. Let us help you improve patient outcomes while increasing your revenue.