How (and Why) Should You Build an Automated Medical Billing System?

Billing is the lifeblood of any healthcare practice. For the most part, medical billing can be a very complicated and work-heavy procedure with many repetitive processes, but what about implementing an automated medical billing system?

Medical Billing Process

This repetitive nature of medical billing makes it a great candidate for automation and coupled with the fact that several organizations are under pressure to keep the medical billing process as efficient and reliable as possible.

In this article, we cover why medical billing needs automation, which tasks bots can take over, how the billing process works step by step, and how to implement RPA without wasting time or money.

Why Does the Medical Billing System Need Automation?

Automation takes care of every important aspect of medical billing that might seem tedious to a human. Billing errors get identified before a claim is submitted, which results in claims getting paid faster by payers. Similarly, RPA payment solutions can enhance collections by automatically sending patient bill notifications through text or email.

In the United States alone, much money is being spent yearly on healthcare expenses that can be avoided. The following are some reasons why automated medical billing is critical.

Proper Documentation

In an industry where Paper document filings cost $20 per filing process. Healthcare providers fill out an average of 20,000 forms yearly. In medical billing, where lots of administrative paperwork like patient profile creation and registration, eligibility checks, and other billing information validation are being filled daily, error-free documentation should be the goal of every healthcare provider.

Similarly, automation enables providers to comply with HIPAA and other regulations and reduces the number of staff members dedicated to a process while increasing productivity.

Lower Costs

Take RCM, which is the financial process of collecting payments for medical bills to generate revenue for a healthcare organization. Revenue cycle management can be time-consuming and expensive because it combines administrative data such as a patient’s personal information, treatment codes, and the insurer’s name with financial billing information. The recommended amount of receivables older than 120 days should be between 12-25 percent, but automating RCM tasks aid in lowering it to less than 12 percent.

Streamlined Medical Billing

All healthcare providers that have jumped on the RPA train in Medical billing automation can attest that using an outdated billing system risks a high level of unorganized claims processes and unnecessary errors. In 2021, $28.91 billion in payment errors were made as a result of coding errors, according to the Centers for Medicare & Medicaid Services (CMS).

More Time for Patients

When bots take over data entry, claim follow-up and status checks, staff spend that time on patients and on the cases that need judgment. People who no longer repeat the same steps all day also tend to be happier in their jobs, and that shows in the care patients get.

What Can Be Automated in Medical Billing?

A lot of tedious and repetitive processes can be automated in medical billing. Billers have to pull data from separate systems, such as patient history, diagnosis and procedure codes and insurance eligibility, and payment depends on getting those codes right. Here are the tasks bots take over most often.

Appointment Scheduling and Registration

Bots can create patient profiles, register patients and book appointments, and keep the record up to date from the first call until the visit is complete.

Data Entry

Data entry is one of the most time-consuming parts of medical billing and coding, and where most errors start: demographics, codes and insurance details typed by hand. Bots take that information from your EHR or EMR and enter it into the billing system. With OCR, they also read data from scanned images and PDFs, so nobody has to retype them.

Eligibility Checks and Cost Estimates

Bots check a patient’s coverage and benefits before the visit, then link the patient’s profile to the planned services and calculate the cost from the price list you already have. See how this works in our eligibility verification automation.

Prior Authorizations

Bots collect the data a prior authorization needs from payer websites and your other systems and enter it where your team works, such as the hospital information system. More on this in prior authorization automation.

Electronic Health Records Automation with RPA

Regardless of the EHR your company uses, there is always room for automation. Bots fill in EHR forms and copy data between systems, for example from one EHR to another or from your EHR to your CRM, which cuts errors and gives doctors more time with patients.

Claims Processing

Human error is a common cause of first-time claim denials. Bots handle charge entry, payer rule checks and submission, and keep fee schedules up to date, so no claim goes out unpaid or underpaid. Our SuperBill client cut claim turnaround time by about 70% this way (case study), and Gentem reduced manual claim prep by 98% (case study).

Learn more about automated claims processing.

Payment Posting

A payment posting bot follows the rules you give it, the same way you would train a new employee. It posts insurance payments, flags unpaid claims for follow-up, and handles refunds and takebacks.

Denials

Bots fix simple errors and resubmit the claim on their own. Complex denials go to a person, with the patient and denial details already gathered, so the rework is faster. See denials management automation and the case study of an AI agent for denials.

Patient Communication

Bots can write an email that sums up the price of a service or other questions from a phone call, and send reminders by email or text.

Reporting

Bots can run around the clock, and everything that passes through them can feed accurate reports, which makes billing decisions easier.

Thinking of automating your medical billing management? Find out more here.

The Medical Billing Process in 8 Steps

Medical billing might seem complicated, but it comes down to the following eight steps. Bots can help at almost every one of them.

Registration

This is the first step of the medical billing process, where a patient calls to schedule an appointment with a healthcare provider. For a doctor’s visit, a patient has to pre-register effectively by providing insurance details. Information on old works will be saved, and a patient only has to explain the reason for their visit on subsequent visits. Registration enables medical billers the opportunity to verify details provided before claim submission.

Financial Responsibility Check

Financial responsibility checks are carried out to verify a patient’s insurance to know who owes what for a doctor’s visit. Before a biller can determine if a patient’s insurance plan covers the services the patient needs, the biller has to gather vital information that can only be carried out by carrying out financial responsibility checks.

Individuals and companies all have different insurance plans. Hence, a biller has to check a patient’s coverage to ensure certain bills are assigned appropriately and prescriptions are covered for the entirety of the bill. In this case, RPA bots carry out these kinds of checks.

Check-in and the Superbill

Patients are asked to fill out forms as they arrive to separate registered patients from first-timers. The necessary official identification, such as a valid insurance card along with a passport or driver’s license, is used in determining whether copayments are received before or after the enrollment is done by the providing office.

In most cases, Copayments are collected at the point of service, and once the patient has been verified, a report is sent to the medical coder. Upon receiving the medical news, the medical coder analyses it and translates its information into usable medical code. This medical coding process results in what’s called the “superbill.”

The superbill includes demographic information about the patient’s medical history, the physician’s name, the provider’s name, the codes for the diagnosis and procedure, the procedures performed, and other relevant medical information. The superbill is then transferred via a software program to the medical biller.

Coding and Billing Compliance Checks

After receiving the superbill, the medical biller transfers it into billing software or a paper claim form. It ensures that the procedures coded are billable, even though the billability of a system depends largely on the regulations laid out by the payer and the patient’s insurance plan.

Billers must also ensure that compliance standards are met. Typically the code must follow guidelines laid out by the Office of the Inspector General (OIG) compliance standards and the Health Insurance Portability and Accountability Act (HIPAA).

Transmitting Claims

Transmission of claims is done electronically and with coding through the use of EDI (Electronic Data Interchange). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates all health entities covered by HIPAA to submit their claims through electronic means. However, claims will only be transmitted through EDI if they are error-free. Learn how you can improve your claims management by providing RPA for claims processing.

Adjudication Process

This is the stage where a claim is denied, rejected, or accepted. A payer evaluates the medical claim to decide whether it is compliant or valid and how much will be reimbursed to the provider. During the adjudication process, the details of the claims are sent to the biller or provider to know how much they are willing to pay and why.

For patients with secondary insurance, the remainder of the claim is sent to their secondary insurer after approval by the primary insurer. An appeal process can be filled with the payer if any problem arises.

Generate Patient Statements

Patient statements detail all the patient’s care from their healthcare provider. It is the procedure bill, and once the payer sorts the agreed amount, the patient handles the rest. Some payers might include an Explanation of Benefits (EOB) to explain why some procedures were covered and others were not.

Follow Up On Patient Payments

Bills must be paid on time to ensure a system functions without issues. Billers are charged with mailing out timely, accurate medical bills to ensure bills get paid on time. Each provider has its own set of guidelines and timelines when it comes to bill payments, notifications, and collections. The biller’s responsible for ensuring that the provider is properly reimbursed for their services if the patient does not pay the full amount or is delinquent in their payment.

Learn more about five processes for the healthcare industry you didn’t know could be automated.

The Steps for Implementing an Automated Billing System with RPA

1. Audit your processes and confirm the requirements. Pick the processes to automate and rank them by complexity and return on investment. Decide what each automation should achieve and how it fits into your operations. RPA consultants or an RPA services company can map your processes and compare your current tools with your goals.
2. Check feasibility. For each process, check how much of it can be automated and whether that is technically possible. The person who runs the process, a subject matter expert and an RPA expert should do this together, including a check of legal compliance.
3. Fix the process first. If the check shows a process isn’t organized, standardized or documented, fix that before automating it.
4. Write user stories. Describe each step to be automated from the user’s point of view, then turn that into a process description document for the developers.
5. Set up the environment and build. Developers build the workflows in an RPA platform such as UiPath or Blue Prism. Each tool has different strengths, so choose carefully.
6. Test with a proof of concept. Test the automation in every situation you can think of before it goes live, and send any problems back to the developers.
7. Confirm and deploy. Once the issues are fixed, check the results again and deploy the full solution.

RPA in Medical Billing: What to Keep in Mind

Choose the Right RPA Technology

RPA platforms such as UiPath, Blue Prism, Power Automate and Kofax differ in features and licensing costs. Some will suit your needs better than others, so compare them before development starts.

Work with the Right Developers

Your developers need the skills and experience to set up the environment and build the workflows on their own, with little downtime, and to scale the automation later. Here’s what to check before you hire.

Stay HIPAA Compliant

Every workflow and bot must comply with the rules of the market it runs in; in the U.S., that means HIPAA. Penalties for HIPAA violations are severe, whether or not the provider caused the problem.

Manual document work is where omissions and errors creep in: forms need specific information approved by patients, which means chasing people for approvals and skipping steps. Bots that move patient data between systems take those manual steps out.

Read more about HIPAA compliance automation.

Automate the Right Process

Choosing what to automate takes experience: what is actually needed, and which tools and testing methods will get you there. Our guide on which processes to automate can help.

Track the Right KPIs

Pick KPIs based on the outcome you need, such as productivity, return on investment or less downtime. More in our guide to measuring RPA success.

Automated Medical Billing – Conclusion

A streamlined workflow makes for a less hectic workday. An automated billing system helps healthcare providers reduce human mistakes and process claims accurately.

Every organization’s needs are different, so start with an assessment of your own processes, requirements and KPIs by people who have done it before. That avoids wasted time and money and leaves room to scale later.

Our in-house RPA developers, including UiPath consultants, can help you automate your medical billing by connecting your health data systems. Get in touch for a free consultation.