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!

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