As stated earlier, the job of the medical biller aligns closely with that of the medical coder, but there are other integral tasks that are unique to the medical biller. As you read in Course 2, the initial part of the medical billing process is the collection of data from the patient. Medical billing specialists must ensure they have all the relevant information from the patient and that this information is correct in order to proceed with a claim to the insurance company.
Once medical billers have the correct information regarding a patient’s history, contact information, and insurance policy (or policies), they then input that information into their medical claims software and begin the claims process. Upon translating the procedure notes into diagnostic and procedural codes (or upon receiving these codes from a third-party coder), the medical biller creates an insurance claim and sends this to an insurance company. Medical billers should be familiar with claim formats for each of the major payers, including Blue Cross/Blue Shield (and other private payers), Medicare, Medicaid, TRICARE, CHAMPVA, and various worker’s compensation and disability organizations.
When the claim is returned and the healthcare provider is properly reimbursed for services, medical billers must then bill the patient. This process involves following up with patients about late payments or arranging for a collections service in the case of notably delinquent bills. Medical billers are also responsible for interpreting the Explanation of Benefits (EOB) and explaining the general billing process to patients. Medical billers must be familiar with co-pays, coinsurance, and deductibles in order to bill patients correctly.
If a claim is returned to the healthcare provider as denied or rejected, the medical billing expert must determine why and correct errors if possible. If the claim was denied because of inaccurate or inappropriate coding, the medical biller must input the correct codes and resubmit the claim (or pass it back to the third-party coder who initially coded the procedure).
Medical billers must also prepare appeals to denied claims on behalf of patients or the healthcare provider. A denied claim may be due to a clerical error (as with a missed code), or it may come down to a discrepancy in the provider’s contract with a payer. Medical billers also have to help patients prove the necessity of their medical procedure. They must be prepared to research all of the elements of the appeals process. As with coding, the appeals process is time-sensitive, so medical billers handling claim appeals must work quickly and efficiently to ensure their appeal is filed in a timely manner.
See What Tools You Will Use as a Biller and Coder
Many professionals in the field rely heavily on billing and coding software. This software is especially important if you are planning on working from home. Software like Medisoft or MediTouch allow coders to look up specific codes for accuracy and create claims quickly. There are dozens of billing and coding software programs at various price points, and you will have to assess what your individual needs and preferences are when it comes to the coding software you use.
While medical billing and coding software is becoming an industry standard, some smaller practices still use paper hard copies for their coding and billing services. Paper is less efficient than electronic records, and can create problems such as duplicate data (in the case of there accidentally being two separate files for one patient), not to mention the massive amount of physical space needed for storage of paper claims. Coding and billing via hard copy also makes it difficult for different parties (like other insurance companies or healthcare providers) to access important health records. Still, despite the clear advantages of electronic health records for the purposes of billing and coding, professional billers and coders should familiarize themselves with hard copy billing and coding forms. Medical billers also have to refer to hard copies of a patient’s medical records and EOBs throughout the day when creating a claim.
Find Out What Regulations You Have to Follow
While there are no laws that apply exclusively to medical billing and coding, billers and coders must operate within the laws and regulations that govern the whole of the healthcare industry. Because the information they handle includes confidential patient medical histories, they must follow guidelines laid out in the Health Insurance Portability and Accountability Act (HIPAA), and the Correct Coding Initiative, which is a project of the Centers for Medicare and Medicaid (CMS).
Title II of HIPAA, also known as the Administrative Simplification Statute, ensures that the confidentiality of patients will be secure when their information is transmitted electronically. This applies to all entities that handle health information electronically, including health plans, healthcare providers, and healthcare clearinghouses. These rules also apply to any off-site or third-party entity (such as a freelance biller or coder) that handles sensitive healthcare information. The HIPAA Administrative Simplification Statute states, effectively, that all parties capable of accessing or transmitting sensitive health information have a set of rules in place that a) protect patient health and b) identify which employees or persons will have access to a particular level of private information. Privacy rules may vary from one practice to another, and HIPAA mandates internal audits as a primary method of ensuring adherence to the law. Audits may mean a routine review of protocol and procedure for the medical coder and biller.
Note that this part of HIPAA applies only to electronic transactions, including claims and encounter information (such as ICD-10-CM codes) and inquiries into claim status. Healthcare providers, coders and billers, clearinghouses, and insurance companies are not required to submit this information electronically, but if they do, they must follow HIPAA guidelines.
The Correct Coding Initiative provides detailed guidelines for professional coders and billers. Updated annually by CMS, the initiative ensures that the codes used for various medical transactions are uniform around the country. You are already familiar with certain initiative regulations: The initiative mandates that Current Procedural Terminology (CPT) be used to code medical procedures, and that ICD-10 be adopted by October 1, 2014 for all diagnostic reports. The Correct Coding Initiative also regulates which codes will be used in pharmacy and dental transactions. The medical biller and coder should be aware of these regulations and be able to research them whenever the need arises.