Medical Billing Services

The Job and the Process

medical billing

Medical billing is a central part of any health care practice. Medical billing is the process of translating, submitting, and following up on claims with health insurance companies in order to receive payment for services rendered by a health care provider. The medical biller is responsible for following the claims process to the end in order to ensure the practice receives reimbursement for the work the health care providers perform.

Although patient care is top priority, a medical practice is still a business. To make sure physicians are getting paid for the services they provide, they'll need knowledgeable and reliable staff managing the practice’s billing. Outsourcing the billing process to a professional medical billing service helps redirect a practice’s medical staff resources and focuses attention to taking care of patients’ needs. Hiring an external billing service also generally increases the amount of a practice’s accepted claims and payments, allowing health care professionals to be paid more with less stress and still meet the national regulations.

The question of whether or not to outsource medical billing operations weighs heavily on many doctors and other health care personnel. Medical billing regulations are complex and often change. Keeping staff up to date with the latest billing rules can be difficult. By using a medical billing service, facilities can take advantage of the service’s expertise and coding knowledge to maximize insurance payments. The types of billing services that are usually outsourced include: invoicing, insurance verification, collections assistance, referral coordination, and reimbursement tracking. Third party medical billing services have increased in popularity because they have shown to reduce costs and to allow physicians and other medical staff to focus on health care without having to worry about the administrative tasks that consume time.

Medical Billers Job Description

Medical billers must understand how to read a medical record and are typically in charge of assembling all data concerning the patient’s bill. Such information can include visitation notes, claims transmission, payment posting, insurance follow-up, and patient follow-up.

Because electronic medical billing is a process that involves a health care provider submitting claims to health insurance companies, medical billers are encouraged, but not required by law, to become certified. By taking an exam such as the CMRS Exam or RHIA Exam a medical biller can become certified. These certifications are intended to provide a theoretical grounding for those entering the medical billing field and creates an understanding between the insurance and provider relationship.

CMRS Exam

A Certified Medical Reimbursement Specialist (CMRS) credential is a national certificate provided by the American Medical Billing Association. CMRS certification is voluntary. Although there is no law requiring a medical billing professional to become certified, the goal is to provide a professional certification that recognizes a recipient of having a high standard of knowledge and competency in the field of medical billing. Sections on the exam cover insurance, medical terminology, information technology, fraud and abuse, compliance, and a few other categories. You may find a CMRS Study Guide in each of the current year’s code books. The exam is comprised of 80% of the study guide. This exam is recognized by coders, billers, and employers.

RHIA Exam

A Registered Health Information Administrator credential is a professional certification administered by the American Health Information Management Association, resulting in licensure for health information management. The RHIA certification prepares recipients for careers in health information and medical records management, including systems that capture and report on health care-related data for care performance evaluation. There have been a rise in job opportunities throughout the healthcare industry for RHIAs existing in nonpatient care, managed care and other settings. Review the eligibility requirements for the RHIAs to be sure that having completed the academic requirements for the RHIAs are enough. Early testing is available if you are in your final term of your CHIIM-accredited program.

How much do Medical Billers earn?

A medical biller’s earning potential varies depending on where they live, work, how much they work, education/certification, and related experience. According to the American Academy of Professional Coders (AAPC), the average medical biller earns an annual salary of over $60,000. The AAPC predicts that the medical billing and coding profession is expected to see substantial employment growth of 21% by 2020. Salary.com offers the average annual salary for a Medical Billing Clerk is $34,388 in 2016, enter your specific data to get more information on local average medical billing salary by city, state or zip code.

How to become a Medical Biller

Medical billing is generally available to those with a high school diploma or equivalent GED certificate. However, many employers have begun looking only at candidates who have certification. In order to have a competitive advantage in the job market, expect to learn basic medical terminology and diagnosis, procedure, supply, and medicine codes. Be sure to also stay current with governmental laws and regulations governing the healthcare industry (i.e., the Health Insurance Portability and Accountability Act, Affordable Care Act, Stark Laws, False Claims Act, and Fair Debt Collection Act).

The Process

The medical billing process may seem long and complicated, but it’s actually comprised of eight simple steps:

Register Patients

When a patient calls to set up an appointment with a health care provider, their information and reason for the visit is filed with the provider.

Confirm Financial Responsibility

Financial responsibility determines who owes what and how much for a doctor’s visit. Once the biller has the pertinent information, they can determine which services are covered under the patient’s insurance plan. If the patient’s insurance does not cover the service being provided, the biller must make the patient aware that they will be expected to cover the entirety of the bill.

Patient Check-In and Check-Out

When the patient arrives at the health care facility, they will be asked to complete some forms or confirm the information on file, as well as provide some sort of official identification (i.e., a driver’s license or passport) and a valid insurance card. The provider’s office will also collect co-payments during patient check-in or check-out.

Once the patient checks out, the medical report from that patient’s visit is translated into medical code. This report is called the superbill. The superbill contains all of the necessary information about the medical service provided for the creation of the claim: the names of the provider, physician and patient, the procedures performed, and the codes for the diagnosis and procedure. Once complete, the superbill is then transferred to the medical biller.

Prepare Claims/Check Compliance

The medical biller takes the superbill and inputs it into a claim form. Billers will then send the amount they expect to be paid by the client as laid out in the contract between the patient and provider.

While claims may vary in format, they typically have the same basic information. Each claim contains the patient information and the procedures performed during the visit. Claims also list the provider and a Place of Service code detailing what type of facility the service(s) were performed in.

Billers must also ensure that the bill meets the standards of billing compliance. Billers must follow guidelines laid out by HIPAA and the Office of the Inspector General.

Transmit Claims

Since the 1996 HIPAA, all health entities covered (providers, clearinghouses, and payers) by HIPAA have been required to submit their claims to insurance companies electronically. The submission process itself presents unique challenges because of the standardized claim forms used industry wide, the CMS-1500 (the standardized claims submission form) and the UB-04 (the institutional providers’ uniform bill). The medical biller is responsible for accurately completing and understanding these forms.

Monitor Adjudication

Once a claim reaches a payer, it undergoes adjudication, a process in which a payer evaluates a medical claim and decides whether the claim is accepted, denied, or rejected, and how much of the claim the payer will reimburse the provider for if accepted.

An accepted claim is one that has been found valid by the payer, however, accepted does not mean that the payer will pay the entirety of the bill. Rather, the claim will be processed within the rules of the arrangement between the insurance company and patient.

A rejected claim is one that the insurance company has found some error with, for example missing information or miscoded procedure or diagnosis. If rejected, the claim will be returned to the provider for correction and resubmission.

A denied claim is one that the insurance company refuses to process for the services rendered. This may occur when a provider bills for a procedure that is not included in a patient’s insurance plan.

Once the adjudication is completed, the payer will send a report to the provider, detailing what and how much of the claim they are willing to pay and why. The provider then reviews this report, check to make sure the codes listed on the payer’s report match those of the initial claim, and check to make sure the fees in the report are accurate according to the contract. If there are any discrepancies, the provider will file an appeal with the insurance company in an attempt to secure the proper reimbursement for the services.

Generate Patient Statements

Once the biller has received the insurance report, they create a statement for the patient. The statement is the remaining amount of the bill for the procedures the patient received from the provider that wasn’t paid for by the insurance.

Follow Up On Patient Payments and Handle Collections

The final phase of the billing process is ensuring those bills get paid. Billers are in charge of mailing out accurate bills in a timely manner, and then following up with patients whose bills are not paid. Once a bill is paid in full, such information is stored with the patient’s file. If the patient doesn’t pay or they do not pay the full amount, it is the responsibility of the biller to contact the patient directly, send follow-up bills, or enlist the help of a collection agency in order to ensure payment is made.

The Difference from Medical Coding

Although medical billing and medical coding are two very similar disciplines and salaries, many medical billers are also medical coders and vice versa, there is a difference between the two fields. Medical billers focus on providing accurate and timely reimbursement based on the codes used; while medical coders concentrate on the transformation of health care data into universal medical alphanumeric codes.

While both professions strive to the adhere to the guidelines and regulations, medical coders usually deal in a wider range of coding theory, while medical billers are more knowledgeable about commercial insurance requirements and what codes can be billed. Another difference between medical coders and billers are the types of certifications available for each profession. Medical billers are given two certification options: Certified Medical Reimbursement Specialist or Registered Health Information Administrator. Medical coders are offered six: Certified Professional Coder, Certified Outpatient Coding, Certified Inpatient Coder, Certified Risk Adjustment Coder, Certified Professional Coder – Payer, and Specialty Coding Certification.

Conclusion

The daily operations of medical practices often go hand in hand with the billing process. Therefore, most medical billing services offer practice management and electronic health records programs in addition to their billing services, or they will integrate their billing process with the practice’s current system. Keep in mind that good electronic records programs should be certified to help the health care facility meet the “meaningful use” standards of the 1996 HIPPA.

Every day it seems like something new is changing in the insurance world. Keeping up with that rapidly changing and expanding knowledge base of the insurance world is time consuming and frustrating. A medical biller’s job is to know and incorporate the most up to date information on industry regulations, procedures, and requirements so medical professionals don’t have to.

While looking for the best medical billing for a practice, be sure to focus on the companies with extensive experience in working with patient information and insurance claims. Billing errors can cause significant problems for a medical practice and patients, so look for a service that has tools in place to minimize claim rejections and denials. Also, be sure to stay to date with the latest government regulations to avoid penalties.

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