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What is Medical Billing?

Medical billing is the practice of submitting claims to health insurance companies, or the United States government, specifically Medicare, to receive payment for medical and health care services and supplies that were provided to a patient. Each time apatient has received medical attention the healthcare provider's entries into the patient's medical record have to be reviewed and then billed. In the medical billing world, payment for medical services is called reimbursement.

Medical Billing Procedure:

medical billing professionalMedical Billers have one goal: billing for medical and healthcare services, medications, equipment, supplies and consultations. For a medical facility, or healthcare provider to get paid, a claim has to be coded and submitted to the health insurance company, government, or private entities for payment. The medical biller makes sure that claims for these services are analyzed, verified, documented and forwarded to the responsible party, such as a health insurance company, or the patient directly for reimbursement.

The medical biller sends a claim to an insurance company, post payments, respond to outside information requests that relate to the claim, follow up on a claim with no response, communicate with the patient or their insurance company about a claim that is denied, in review or pended.

Medical billers also send billing statements to the patient and turn over delinquent accounts to the providers debt collection agency. Doing it right requires a broad range of knowledge and understanding of the medical billing process and health insurance company rules. 

Medical Billing Check Points

If a medical coder has already coded the claim then the medical biller is one additional "check-point" along the processing path to make sure all medical services the doctor, or provider rendered were properly identified and coded. If a claim is rejected, down-coded, or incorrectly paid it usually lands back on the medical biller's desk to be appealed. That's where it can get complicated. Basically, we stay within the boundaries of our training. Medical billers are not medical coders, and medical coders are not medical billers.

What Medical Billers Are NOT:

  • Medical coders
  • Medical practice managers
  • Credentialing staff
  • Contract review staff
  • Physicians
  • Lawyers

One of many rules of medical billing:

We don't bill what wasn't documented as being provided by the doctor. If it isn't documented as being done by the doctor, it doesn't exist.

If a patient removed a splinter form his finger himself and came to the doctor later to see if it is infected, or pieces of splinter still remaining in the site the medical biller will have to verify the exact procedure that was performed via the doctor's note in the medical chart. The medical biller cannot charge for the splinter removal done by the patient, but can charge for the visit to examine the finger. Read this in depth discussion about procedure coding rules in our forum.

Traits of a Successful Medical Biller and Coder

Medical billers and coders who are accurate and detail oriented, know what data must be included in a clean claim, avoid errors and rejections, stay on top and ahead in their game are the ones most likely to succeed in this highly competitive occupation. Also, good organizational, clerical and people skills are important traits. High school courses in mathematics, health, biology, typing, bookkeeping, computers and office skills will certainly help to pave the way for a successful career path. Conscientiousness, sense of responsibility and respect for the confidentiality of medical information are also important traits clients, mostly doctors, appreciate and value.

A good medical biller knows:

  • Medical terminology
  • Insurance Terminology
  • Coding Basics
  • The claims process
  • The claim form
  • EOBs
  • Aging Reports
  • AR Recovery
  • Clearing Hoses
  • Customer service

For further info you can contact - Medical Billing Service
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Medical Billers Do All That!

Medical billers are the ones who organize medical bills and statements, comb through them for errors, negotiate with collection agencies, answer patient's questions about their health-care plans and the office's billing routine, and spend hours on the phone with insurance companies on a client's behalf. Think about the large number of medical specialties, countless medical conditions and diseases, plethora of CPT codes and Medicare rules, the multitude of health insurance companies (payers) and millions of patients everywhere!

medical coding bullets COMPLETING CMS-1500 AND COMMERCIAL CLAIMS. Billing guidelines for inpatient medical, in/outpatient global surgery, minor surgery, and maintenance of a provider's claim files; setting up a filing system for completed claims; determining primary and secondary status; completing common types of claims.

medical coding bullets KNOWLEDGE OF BLUE CROSS AND BLUE SHIELD HEALTH INSURANCE PLANS. Features of BCBS plans; correct filing procedure; completing a BCBS claim form.

medical coding bullets KNOWLEDGE OF MEDICARE. Parts of the Medicare program; eligibility criteria; fee schedule; supplemental plans and managed care; filling out an HCFA 1500 claim form.

medical coding bullets KNOWLEDGE OF MEDICAID. Services covered under the federal portion of Medicaid; eligibility; services provided and paid for by state coverage; obtaining preauthorization for services.

medical coding bullets TRICARE AND WORKERS' COMPENSATION. Healthcare for the military; deductibles, cost sharing and eligibility requirements for TRICARE; filing TRICARE claim forms; workers' compensation programs; classifying on-the-job injuries; preparing a First Report of Injury form; qualifying for workers¹ compensation benefits.

For Example:
If the practice administers 50 different procedures and works with 50 payers, then 1,000 monthly charges require selection from 2,500 unique fees defined by contractual agreements or “reasonable and customary pricing” (“allowed”) for every CPT-payer pair. Wow... that's huge! The medical biller's role in this process is to translate medical terminology, diseases, diagnoses into coded billing statements, enter patient information into databases, mailing patients’ billing statements, posting payments received, follow up on unpaid insurance claims, as well as appeals and denials, and report to their employers on the financial status of the practice.

Assignment of Benefit (AOB)

This term has two distinct words that describe what it is.

  1. Assignment (taking something and giving it to someone else)
  2. Benefit (what the insurance company is paying when it pays a claim. A claim is a request to have a benefit paid)

So when you assign a benefit, you are submitting a request to have the payment of the patient's health benefit sent to a designated person, persons, or entity. A health insurance company has no obligation to honor this request. On the other hand, the patient's contract with their health insurance company may prohibit the patient from assigning the benefit payment to anyone, so having the patient sign 1,000,000,000 of them are useless. If the contract prohibits the assignment, signing a form won't change the contract. There is an exception to this: at least two states, Louisiana and Florida have laws that requires the insurance company to honor the AOB. In Florida, this is with emergency care.

Thank goodness it is not the doctor's job to do the billing!


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