Medical billing specialists and insurance companies work hand in hand. The bill or claim begins when a patient visit his or her physician. Office staff create a chart on said patient. This chart includes the demographics of the patients. In addition to this there is also the patients physical/ medical information. All medical procedures, treatments and diagnoses are listed in this chart making it a highly private piece of information. After the patient finishes with the visit, the physician or qualified staff will assign a CPT code to the visit for medical billing. This CPT code (Current Procedural Terminology) defines the level of care that the patient received. This assigned code is based on the extent of the physical exam, the complexity of the medical visit and the patients medical history. The physician will also offer a diagnosis for this patient and the visit. The diagnosis will have an attached number called an ICD -9-CM.

Both the CPT code and ICD 9 – CM along with the claim are then submitted to the insurance company by the Medical Billing specialist. The insurance company will then have their medical director review the claim. This review will determine the legitimacy of the claim based on the patients eligibility, medical necessity and the providers credentials. If the claim is approved then payment, at a percentage, will be made to the provider. If the claim is denied then a notice is sent to the provider with an explanation attached. This has to be researched, corrected and then resubmitted. This process can be repeated many times until the insurance company agrees to pay or the provider agrees to accept little or no payment for the service.

Due to the increasing complexity of claims and data entry errors, it is not uncommon to see claims denied about 50% of the time.