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 is a systematic procedure of billing and collecting professional fees for medical and healthcare services provided by doctors and other clinicians to patients.

Medical 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.

A typical case scenario:
A medical biller might receive a chart regarding a patient that came in for a mass in the right breast; the diagnosis is mastitis. It was documented that the site was red and firm, weeping fluid on its own at the patients home early that morning before the appointment. It was then determined that the patient had an abscess and was charged for the visit and several injections.

While reviewing the charges, the medical biller notices that one of the injections was a form of local mac sedation, which leads to a more closer review of the note to see if a procedure was performed but charges were not carried over. The medical biller reviews the note, and notices that the provider states under the procedure outline: "Skin abscess some fluctuation noted, drained through opening a small amount of yellow tinged fluid". The medical biller must now call that provider to verify whether an I&D was in fact performed or whether the site was opened by the patient before arriving for the visit and drained via the "patient formed opening" as stated in the note.

A similar situation exists if the patient removed a splinter and came to the doctor 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.

If you try to bill for what the patient did, you will have a very angry patient on your hands, a very angry insurance company for trying to bill for services not rendered, which can be called fraud, and you might face a lawyer suing you or a regulatory agency to take your doctors medical license away for fraud. Read this in depth discussion about procedure coding rules in our forum.

Why Won't Doctors Do Their Own Medical Billing?

Traditionally doctors graduate from medical school with the expectation that they will practice medicine and deliver patient care. Running a business, however, is not part of the their premise. Thanks to the medical biller, doctors don't have to do everything themselves.

This means:

• collection of accounts receivables
• co-payments
• claim denial appeals
• and reminders for past due accounts

To them, running a business is best left to business professionals, however, the catch twenty-two is that most medical practices ARE a for profit business (unless they are run as a charity) and need to be properly managed and run as such, therefore their only option is to hire professionals to run administrative and bookkeeping procedures.

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!

 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.

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

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

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

 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!

Post Your Medical Billing Job  We are enrolled in the Indeed Publisher Program and their job search tools are included on our site. Your job ad appears throughout the Indeed network and on our medical billing job website for the next 30 days.