Most practice administrators understand that virtual billing staff work with claims and insurance paperwork, but they don’t truly know what the day-to-day operations are. It’s not just sitting behind a computer entering numbers. It’s problem solving and detective work and inter-office communication on a grand scale all from the comfort of someone’s home, with these team members working behind systems that many people will never see.
The more practice administrators understand what their virtual teams actually do, the more they want to move their billing efforts to remote teams. It’s not out of laziness or a desire to control the costs; it’s an understanding that there are people who do this all day long from their homes without interruptions instead of being in a bustling practice with constant needs pulling them away from the task at hand.
What’s the First Step in Virtual Medical Billing? What Came In While We Were Out?
For virtual medical billing teams, the work day typically starts with a review of what came in since everyone logged off. Insurance companies work at night and process claims. Thus, the morning responses are rife with what was paid, denied, pending for additional information or investigation needed.
Virtual billing staff log into the practice management systems for each practice they’re assigned and likely have a dashboard greeting them with flags for immediate needs. A claim is denied for missing information; it must be worked on today to avoid filing times running out. A payment came through but only partially; there is no documentation with it that needs attention by the end of the day. A patient called yesterday and will need to be followed up upon today.
It’s this morning perusal that lets the virtual teams set their priorities for the day. Are there any denials due immediately? Which insurance companies are known for making staff wait during hold times? Who has the most dire need for cash flow? This information helps team members prepare the organization for success through deadlines, dollar amounts and complexity.
Claim Submission: It’s Not as Easy as It Sounds
Submitting a claim sounds like it should be a straightforward part of virtual medical billing. Yet if someone doesn’t know what they’re doing, it’s where a majority of billing issues come from. Each insurance company has specific requirements for how they want information formatted, medicare one way, Blue Cross another, along with frequently changing specifications.
Subsequently, it’s something virtual assistants spend a lot of time doing, submitting claims, after scouring what bills need to be filed and which can be tossed out or never should have been created in the first place. Team members must check the diagnosis and procedure codes for alignment. They must verify that on service date, active insurance was available. They must confirm any pre-authorizations required are found in the file.
For those practices dealing with staffing challenges or billing backlogs, many are finding that virtual medical billing help keeps claims moving through the system accurately and on time, rather than piling up while in-house teams juggle competing priorities.
Claim submission occurs electronically through clearinghouses which send to appropriate insurance companies. However, before hitting submit, experienced billers have a process called scrubbing that checks for potential issues. Is there a diagnosis code that does not meet medical necessity for what was performed? Is there a procedure code not covered by that particular plan? Is there missing information that will trigger an automatic denial?
Finding these errors in advance saves weeks down the road when teams hear back from the insurance companies saying there’s an issue.
Denial Management: Where Time Really Gets Sunk
This is where billing work becomes intensive. Insurance denial is never just a denial with an easy fix; they almost never contain enough information. Each denial comes with a reason code, but those codes seldom tell the whole story. For example, denied due to “missing information” could mean a specific type of missing documentation but that information isn’t provided anywhere in the notification that comes back.
Therefore, virtual billing staff spends countless hours on the phone with insurance companies trying to get denial claims paid. They also involve navigating IVR systems that frustrate even the calmest person; telling a machine what’s needed; going on hold; getting rejected by people who cannot see claims before them; endless note taking to ensure that whatever was said gets recorded for future use.
Some denials need appeals with written explanations and detailed documentation from the inside. The biller must read through medical records, pull information out, write a letter explaining why it was medically necessary, reattach supporting documentation and submit with rigorous deadlines as specified by the insurance company for appeal applications.
Other denials occur because the bill was submitted incorrectly. The patient’s insurance ID number could’ve been written incorrectly (digitized). Their coverage changed but HR didn’t inform anyone. These claims are corrected and resubmitted; while it sounds easy, it requires many steps and countless other departments.
Denial work gets opened each day as new denials come in constantly, so staying on top of denial work requires great organization and tenacity. Good billers will keep close notes on each denial; track deadlines for appeals and follow up numerous times before either getting claims paid or appeal potentials exhausted.
Payment Posting
When payments come through either from insurance companies or patients, someone has to post them to appropriate accounts within practice management systems. This is not data entry; every payment must be matched to what it’s supposed to pay, specific claim or patient account.
Insurance payments seldom make sense. The insurance company applied it to deductible, or they paid at contracted rate vs standard fee or an adjustment was made based on company policy. The biller needs to ensure amounts are correct based on contracts negotiated.
Additionally, when payments don’t align with what was expected, investigation requires determination. Did insurance incorrectly process payments? Is there a contractual issue that needs higher level attention? Should the balance be billed to patients or written off as contractual adjustment?
Patient payments must be investigated as well. Someone may have paid $500 and has three different outstanding balances across numerous dates of service. How is that payment applied? Does the practice have a policy on applying payments to oldest balances first or largest balances? These decisions impact what goes out on patients’ statements and can create confusion if not handled uniformly.
Patient Billing and Communication
Billing virtual teams handle patient billing inquiries throughout the day, depending upon how the practice runs its communication system. Sometimes these calls get funneled directly to virtual teams; sometimes these calls get taken down by front desk who pass along messages in an email thread. Patient portal messages as well as email inquiries all need replies.
Inquiries come from wanting payment plans but disputing what they think insurance should have paid but requesting detailed statements and trying to understand what happened over which dates. Billing staff must have access to both systems sometimes involving clinical documentation from portals.
Hence, fielding this communication means patients need to understand what’s going on without receiving too much technical jargon. Why did insurance only pay part of the visit? What’s the difference between copay vs coinsurance versus deductible? Why did the patient just get this bill four months later?
Virtual teams must be technical and customer service friendly; a frustrated patient could become an ex-patient quite quickly if interaction doesn’t go smoothly.
Insurance Follow-Up on Pending Claims
Pending claims are neither paid nor denied, but sit languishing in limbo. Insurance companies request additional information or simply process prior authorizations over time. Follow ups go into pending claims with virtual teams dedicated to trying to keep things moving.
They call insurance companies to determine where claims sit; they respond asking additional information but now have it; they escalate when things sit too long in pending. Each company has different policies, experienced teams know who needs follow up more aggressively than others when review takes time.
It’s crucial to ensure claims do not age unnecessarily; the longer they sit without movement, the harder it becomes to collect them, and some insurance companies have submission timelines where if something sits pending after it expires, practices will lose out since they can no longer collect.
End of Day Review
At days end, virtual billing staff assess what occurred during their time online and what’s still hanging around. Which denials are still waiting for resolution? Which companies haven’t followed up? Which practices most need assistance tomorrow?
This type of organization helps facilitate consistency across those team members who work collaboratively since some virtual medical billing pros may tackle one practice while others step in during other shifts so clear notes and organized tasks help facilitate nothing gets lost in translation where different team members pick up where others left off.
Medical billing “work” occurs behind the scenes most often, not visible to patients or practice staff most of the time, but intricate and intensive and detailed work that allows practices to receive effective revenue cycle management sooner rather than later. Having dedicated teams focused solely upon this work without telephones ringing or patients at desks distracting them serves as just one more reason why remote solutions work best for those practices looking for enhanced revenue collections.
