Friday, June 1, 2012

Medical Billing

What is Medical Billing?

Medical billing & coding is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government sponsored programs. Medical billers are encouraged, but not required by law to become certified by taking an exam such as the CMRS Exam, RHIA Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field.

So what does a Medical Biller do?

Basically everything involved to get a doctor or other health care professional paid for their services. This is both payment from the insurance carrier and the patient. A medical billing specialist should be detailed oriented, have good math and data entry skills, understand insurance claims procedures, medical billing terms, medical diagnosis codes, and become familiar with medical billing guidelines.

Medical Billing as a Profession

A medical biller is not a medical coder, but a medical biller might need basic medical coding knowledge, since both disciplines are so closely related and co-dependent.

We can't discuss medical coding unless we also speak about medical billing, so closely are these two tied in with each other. Both discipline's goal is to assure that medical reimbursement claims are promptly processed and submitted to health insurance carriers, and the health care provider and facility gets paid for medical services rendered.

A Medical Biller Is...

Medical billers must understand all aspects of common health care and medical insurance options, including the different plans, carrier requirements, and state and federal regulations. It is also essential that they are able to find and pinpoint relevant information from source documents so that all claims for care and procedures are properly processed. As the saying goes: A medical biller is the provider's key to getting paid!" In order for the doctor's medical practice, clinic, or hospital to prosper the medical biller must know the concept of a clearinghouse and an A/R, and understand how to verify insurance coverage, determine eligibility, collect data, submit all claims, avoid denials, contact patients and communicate with insurance companies to ensure the highest possible return of revenue for their employer, or client.

Medical billing for facility-based providers is different from billing for non-facility based providers; just like inpatient coding is different from outpatient coding. Health care provider billing involves submitting claims for individuals, such as physicians, chiropractors, nurse practitioners, physical therapists, podiatrists, dentists, etc.; hospital billing involves claims for inpatient services, which, in turn is different from ambulatory emergency services for people who were treated in the ER, but not admitted to the hospital's nursing ward.

What are Billable Health care Costs?

The biggest segment of health care cost and expenses comes in form of bandages, prostheses, devices, implants, medications, equipment, apparatuses, and countless other items required for modern care. These items and the services associated with them must be properly coded and billed to the patient, or their health insurance provider for reimbursement. This also includes wound care, and hospital stays. Understanding the reason for an insurance company's claim denial is very important.

Submitting Medical Claims

Submitting medical claims is just as diverse as any other job. The medical biller must know the claims processing guidelines for common health care plans, such as Blue Cross/Blue Shield, Tricare, Medicare and Medicaid, etc, and state regulations that apply. There are three basic areas for billing:

  •   inpatient hospital 
  •   outpatient services 
  •   physician billing

This goes along with other sub-areas of specialized billing, such as for DME (durable medical equipment), and for home health care, these are the three areas most entry level medical billers are expected to handle.

Do Medical Billers Code?

A medical biller with enough medical coding knowledge is certainly capable of verifying that medical codes are used correctly, however, the initial medical coding process is not necessarily their forte. Why? Because often they are not specifically trained in medical coding. If they attempt to do it anyway and something goes wrong it can create liability for them. The medical biller's strength lies in their knowledge of different health insurance plans, provider contracts, state rules and regulations and getting denied claims overturned and paid when the denial was incorrect. Of course, experienced medical billers with enough general knowledge of the medical coding process are certainly allowed to handle the medical coding and billing process from start to finish.


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  3. My cousin recommended this blog and she was totally right keep up the fantastic work!
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