Getting to Know North Shore Health
The Life of a Healthcare Bill at North Shore Health
By: Kathy Bernier, CCS: Director of Health Information
Why Does It Take So Long? Sometimes patients are surprised by how much time has passed between their visit and their bill. We occasionally hear patients ask, “Why am I just getting this bill now? I was there months ago!”
It's a fair question.
Healthcare billing is very different from buying something at a store. At checkout, the price is known and the transaction is finished. In healthcare, the final patient responsibility often can't be determined until the care is documented, coded, billed, and processed by insurance.
Every step has a purpose and accuracy matters. A mistake at the beginning can affect everything downstream. That's why accurate registration, complete clinical documentation, correct coding, clean claims, and careful insurance follow-up are all important parts of the same process.
Let's follow the life of a healthcare bill at North Shore Health.
It Starts with Patient Access: The revenue cycle actually begins before many patients ever receive a service. Patient Access registers all patient types at North Shore Health. Our team verify demographic and insurance information, obtain necessary signatures, and start the prior authorization process when required.
They also create the patient visit, or encounter, that connects everything that happens afterward.
For example, when a patient comes in for lab work or imaging, or even drops off a specimen, there needs to be a visit created in the system. That visit connects the patient to the provider's order, the service performed, the result, the medical record, and eventually the bill.
This is one reason Patient Access may ask to see your insurance card again or ask questions you've answered before. Getting it right at the beginning helps everything that follows go more smoothly.
Next Stop, Documentation: Once care is provided, the story of the visit is documented in the patient's medical record. Providers, nurses, therapists, lab, imaging, and other clinical staff all contribute documentation depending on the services provided. This documentation isn't only important for patient care, it also tells the story that supports what North Shore Health can bill.
And sometimes, our Health Information Management (HIM) team has to do a little detective work. If something is missing, incomplete, or unclear, the record may need additional review before the account can move forward.
Then It Reaches Health Information and Coding: Once the documentation is complete, HIM and Coding review the medical record. Coders translate the patient's diagnoses, procedures, treatments, and services into standardized medical codes. Those codes help tell the insurance company why the patient received care and what services were provided.
Coding isn't simply choosing a code from a list. The code has to be supported by the documentation and meet applicable coding and billing requirements. If documentation needs clarification, the account may need to wait while additional information is obtained.
Now We Have a Claim: After coding and other billing checks are completed, the information is turned into a claim and submitted to the patient's insurance company.
At this point, North Shore Health isn't necessarily getting paid yet and does not control the timeline.
The insurance company receives the claim and processes it according to the patient's coverage. They may pay the claim, apply part of the amount to the patient's deductible or coinsurance, request additional information, deny part of the claim, or send it back because something needs to be corrected. Sometimes North Shore Health has to provide additional records or information, correct the claim, or appeal a denial before the account can move forward. That can add more time to the process.
Finally the Patient Bill: Once insurance has processed the claim and North Shore Health receives the insurer's response, any appropriate patient responsibility can be determined. Then the patient bill can be generated.
That's why a patient may receive a bill several weeks, or sometimes longer, after receiving care. During that time, the account may have traveled through several departments and computer systems and back and forth between North Shore Health and the insurance company.
The complete journey may look something like this: Patient Access → Patient Visit → Clinical Documentation → HIM/Coding → Billing Review → Claim Sent → Insurance Processing → Payment/Denial/Request for Information → Follow-Up → Patient Responsibility → Patient Bill
Healthcare Billing Can Be Confusing! We recognize that insurance and medical bills aren't always easy to understand. If you receive a North Shore Health bill and something doesn't look right, or you simply don't understand why you owe the amount shown, please ask us. We are here to help
One Patient Visit, A Whole Team Behind It: What starts with a greeting from Patient Access eventually touches clinical staff, HIM, Coding, Billing, insurance companies, and others before the process is complete.
So the next time you hear someone say, “Why does it take so long to get a hospital bill?” you will know that bill has probably been on quite a journey!
For more information, visit: https://www.northshorehealthgm.org. Stay tuned for future informative “Getting to Know North Shore Health” articles, published monthly in the Cook County News Herald.