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Community health is a healthcare sector specializing in the physical and mental well-being of people within their community—providers specializing in this focus on providing top-of-the-line care to those in their geographical area. Community health billing is complicated, involving quite a bit of a provider’s time and attention. To optimize revenue, billing processes must be followed strictly. Providers need a firm grasp on the revenue cycle, how it works, and how to bill insurance. So how does community health insurance billing work, and what can your organization do to perfect it? 

What is Community Health Insurance Billing? 

Community health insurance billing is the process of a community healthcare organization submitting a claim for financial reimbursement on behalf of the client/patient for rendered services. If a patient did not have insurance, you would bill them directly for any services you provided them. Community health insurance billing is the process of first billing an individual’s insurance company for payment. Whatever is left at the end of the claim process will be sent to the patient as a bill. 

There are different types of insurance that community health organizations might bill to. 

Billing to Private Insurance Billing Companies: 

A private insurance plan is not run by a state or federal government. This type of insurance can be purchased in various ways but is most commonly acquired through a patient’s employer. There are over 900 private insurance billing companies in the United States that all have differing requirements for how they wish claims to be submitted. This is part of why community health insurance billing is so complicated. 

There are usually a handful of popular insurance companies in a single geographical area. This means that organizations will not have to bill all 900 companies, and instead, they will only have to bill to the ones they choose to, usually the most used players in your area. 

To bill a private insurance company as an in-network provider, you must join their provider panel. This is referred to as the credentialing process and is essentially when a provider applies to be an in-network provider for that payer. You can still bill to this company, even if you are not a paneled provider. The difference is that you will be considered an out-of-network provider, which will usually result in a higher cost of care for the patient. 

When billing to multiple private insurance companies, you will need to keep close track of each payer’s billing requirements as well as their billing cycle. Electronic billing software can be beneficial in keeping track of all of these complicated details, helping you file claims on time, and making sure you optimize your revenue cycle. 

Billing to Medicare 

Medicare is an insurance that is regulated and run by the federal government in the United States and is considered public insurance. The government regulates how much a provider is paid for specific services rather than them deciding their own rates. Providers have to apply to become participating Medicare providers, and it can take as long as 90 days to be approved. Once approved, you file for reimbursement, but there will not ever be a question about the amount you will be paid for different services. The intricacies of Medicare billing lie in the timing and regulations providers must adhere to in order to get paid. 

Billing to Medicaid 

While Medicare is an insurance program, Medicaid is an assistance program. Medicaid is considered a public insurance program that provides health coverage to low-income families and individuals. Patients with Medicaid usually pay little to no costs for their medical expenses. This is considered a federal-state program, which both the federal and state governments fund. The type of insurance varies at the state level and is run by state/local governments. While the federal government sets regulations, providers have to apply to be a Medicaid provider at the state level.

Community Health Insurance Billing Software

Billing is time-consuming and distracting, and providers that wish to focus on their clients/patients end up dedicating hours of their workweek to billing and filing claims. The good news is that organizations can simplify the billing process using community health insurance billing software. Billing software can help providers perfect their claims process, adhere to differing payer regulations, and understand their revenue cycle on a much deeper level.