Thinking about becoming a medical billing specialist but want to know exactly what they do? Here you will learn all the medical billing processes and what it takes to become a insurance billing specialist.
I've been an insurance billing specialist both as an employee and business owner for several years now. I got started working for a billing service and eventually started a business in medical billing so I could work from home. I've also spent time working in providers offices helping to improve and streamline the billing process.
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. But as we'll see there's a lot involved with this process.
The medical billing process is extremely important to the financial health of the practice. If claims don't get submitted promptly, the doctors and their staff - including the medical billing specialist - wouldn't get paid.
Some consider medical billing to be a sub-specialty of the field of medical coding. In some situations the medical billing medical coder responsibilities may be performed by the same person.
The medical biller makes sure all the necessary forms and paperwork are completed and approved and enters the information into the medical billing software - also called the medical billing practice management software.
This information includes physician info, patient info (name, date of birth, address, sex, etc.), insurance info, medical billing codes, payment information, and any special notes on the account.
This is all the information necessary to submit claims to the insurance company. In performing their jobs, the insurance billing specialist routinely communicates with health care providers - doctors, nurses, practitioners, assistants, etc. - insurance companies, and patients to obtain and clarify claim and payment information.
Other duties include collecting and posting insurance and patient payments, payment adjustments, billing patients for their responsible portion, following up on unpaid or denied claims, and preparing claim appeals.
In summary, here's the most common responsibilities of the medical billing specialist job description:
Medical billing specialists need to be:
6 Trait of a Successful Medical Insurance Specialist
From my experience working as a medical billing specialist, I thought about the characteristics of those who are successful in this field. If I was going to hire someone, what would I look for?
The Medical Billing Process
When a patient visits a physician, the doctor evaluates the patient and writes down the observed conditions and treatment. This information is then given to a medical coder who takes this information and assigns the appropriate ICD-9 diagnosis and CPT treatment codes and CPT modifiers if necessary.
These codes are then entered on a superbill or patient encounter form. You've probable seen one of these when visiting the doctor. Many physicians don't even use a coder and do this themselves by checking or circling the diagnosis and treatment codes directly on the superbill. The majority of patient visits involve using a lot of the same codes.
This is when the medical billing specialist gets involved. They take the superbill and input the information into the practice management (or medical billing) software. Paper claims are printed out on a CMS-1500 insurance form and mailed to the insurance carrier. Electronic claims are sent electronically either directly to the insurance company or a clearinghouse.
If the claim is rejected, the medical insurance specialist follows up to find out why it was rejected, correct the claim, and resubmit. An appeal may also need to be written and submitted with supporting information to the insurance company.
Insurance & Patient Payments
Once the claim is processed by the insurance company, the payment received from them is accompanied by and EOB (Explanation of Benefits). This information is then entered into the medical billing software. If there is any patient responsibility such as co-pays and co-insurance, a patient statement is printed and mailed. This is usually done in batches on a monthly or bi-monthly basis.
Sometimes a patient has a question about their bill. This requires the medical billing specialist to look up their account information and explain the charges and why they were not covered. Many patients don't understand the limits of their insurance coverage and must be referred to their insurer to explain.
The medical billing specialist should have a good understanding of the different insurance plans and contracts.
A single provider can several different contracts with the same insurance carrier - all with different fee schedules, rules, and covered services.
The physician typically charges more for procedures than what is contracted with the insurance payer. What is paid by the insurance company is called the allowable amount.
A good example of the is a family doctor who charges $100 for a visit. The insurer may pay an allowable amount of only $80. The $20 difference is know as the “write off”. These amounts are typically shown on the EOB or ERA which is received with the insurance payment and posted by the medical billing specialist.
Copays, Deductibles, & Coinsurance
Many insurance plans require a patient to share in the costs through a copay, coinsurance, or deductible. In our earlier example of an $80 allowable amount, if the patient had a $20 copay, the insurance payment would be $60. The patient pays the $20 copay directly to the doctor - usually at the time of service.
If the patient had a $200 deductible, the entire $80 contracted amount would be the responsibility of the patient until the $200 deductible was satisfied. Additional provider charges after the $200 deductible would be paid by the insurance company. A copay still applies even after the deductible is met.
Coinsurance is a percentage of the allowable amount the patient is responsible for. Many insurance plans require coinsurance for surgery and diagnostic tests. For a $100 allowable amount, the patient would be responsible for $20 and the insurance company the remaining $80.
Understand Insurance Payer Contracts
The different insurance companies that pay a provider have a variety of plan coverages for their insured - the patient. The terms of these plans are defined in the payer contract with the healthcare provider. The medical billing specialist should be able to read and understand the requirements of the contract that define:
Payer contracts may be difficult to read and understand so don't be afraid to ask your provider or the insurance company for clarification.
The types of facilities a medical billing specialist works for can be just about any health care provider that submits claims to a health insurance company on behalf of the patient. This would include but not be limited to:
Medical Insurance Billing Software Examples
Here’s some example screen shots of electronic medical insurance billing software to give you an idea of what medical claims billing software looks like throughout the billing process.
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If you are serious about getting into medical billing, I highly recommend an excellent medical billing reference. Understanding Health Insurance by Michelle Green does a good job of explaining the whole health insurance reimbursement process. It also gives a good description of managed care, legal and regulatory issues, reimbursement methodologies, coding for medical necessity, and common health insurance plans. It's available on Amazon. I got this when getting started and it answered a lot of my questions about the billing and coding process.
For this and other helpful books check out our Medical Billing Books page.
The primary medical billing data entry tasks are entering claim information and posting insurance and patient payments. Find out what’s involved with the typical medical billing data entry tasks.
Medical Billing Claims Process
Learn what the medical billing specialist must do to create and process insurance claims both with billing claim medical software and Paper CMS-1500 forms.
Here's a flow chart in PDF format that gives the process in simplified form for healthcare claim processing:
Medical Billing Errors
Healthcare claim processing errors keep a provider from getting paid. Here are some of the most common medical billing errors and suggested medical billing practices to prevent.
Medical and CAQH Credentialing
Medical and CAQH Credentialing explained. The benefits of CAQH healthcare credentialing are discussed.
Medical Billing Collections
There's two types of collections - Patient and insurance - that a medical billing specialist performs.
Patient billing is the process of charging patients for amounts not covered under their insurance plan. Medicare requires the patient be billed for their responsible coinsurance or deductible amount. There are however Medicare patients who can be exempted due to documented hardships.
Most commercial insurance provider contracts require the patient be billed for deductibles , copay's, and coinsurance so it's important the provider understand this.
For our clients we'll typically print statements and mail to the patients once a month. Most medical billing software programs have a feature for creating and printing these statements.
Sending out patient statements for a large practice with many patients can be very expensive. Many clearinghouses offer services to print and mail statements. All we have to do is print our statements to an electronic file and upload to the clearinghouse for processing.
This is a tremendous time saver. Stuffing hundreds of statements into envelopes is very time consuming and labor intensive. Not to mention the logistics of getting all those envelopes mailed.
Also referred to as aging. This is a tedious process which involves a lot of phone calls to insurance companies to determine why a claim was denied. Most insurance companies have an automated phone system that allows you to check status. However entering all those numbers via the phone keypad is tedious for a medical billing specialist. A lot of larger insurance companies may have the ability to check claim status on-line.
A good reason it is so important to get the claim right the first time and avoid all this work. In general the longer a claim goes unpaid, the harder it is to get paid.
Medical Billing Records
There is a lot of paper associated with billing and it has to be organized and filed. Frequently when working on secondary or tertiary insurance claims, we have to retrieve the primary EOB.
We also find it necessary to occasionally dig out an old superbill. It is very important to have and organized filing system. Otherwise you waste a lot of time looking for documents.
A medical billing specialist may occasionally need to write a letter to the insurance carrier requesting payment for a denied claim. This is usually a letter with information such as claim number, date of service, provider identification number, patient group or policy number, why the claim is being appealed, and what action is requested.
Responding to Patient Billing Questions
I get some interesting phone calls from patients sometimes after statement are sent out. When a patient has a question you have to look up their account in the medical billing software and explain their charges. Sometimes they are not too happy about it.
I've learned to be patient and diplomatic when explaining a patient bill. Angry patients are actually very few - especially when the patient statement is formatted to be easy to read with good descriptions of the charges. For my largest practice we typically send out greater than 300 statements a month - and we might get one agitated patient every few months.
Doctors frequently want to know how their practice is performing financially. Most software programs have many useful pre-formatted reports that show a lot of useful information.
Having a software with the ability to customize and filter these reports is very helpful to the medical billing specialist. It seems like every provider has a different preference for practice information.
Working on insurance aging requires running an aging report. If the billing has been neglected this can be rather long.
Other Medical Billing Specialist Knowledge and Skills
Most smaller practices do not have a dedicated coder so it's important to have some coding knowledge to be able to look up ICD and CPT codes and know how they are organized.
Understanding managed care authorization and coverage limits is necessary when investigating unpaid claims. Some specialties, for example mental health and physical therapy, have limits on the number of approved visits.
A medical billing specialist may be required to call and verify the number of authorized visits for a patient. We use our billing software to add reminder notes that pop up when the patient records are accessed to remind us and the front office receptionist.
Medical Insurance Billing Specialist Job Description
Here's a summary for the job description for a medical insurance specialist. Includes the most commonly performed duties and responsibilities of medical billing and coding jobs.
Technology and the Medical Billing Specialist
The insurance billing specialist needs is very dependent on technology to accomplish their job and work more efficiently. This would include the use of computer applications such as browsers, medical claim billing software, electronic medical records (EMR), email, and word processor to name the most frequently used. The understanding of these technology tools – computer and software – is important for medical billing and coding jobs today. In just about any medical billing specialist job – hospital, private practice, billing service, clinic, lab, etc. – using a computer is now like using a pencil was years ago.
Using medical coding and billing software requires being able to enter or edit patient demographic or insurance info, diagnosis (ICD-9), and treatment (CPT) codes, and charges associated with the treatment. The insurance billing specialist is also responsible for posting payments from insurance companies and patients and creating patient statements for balances due.
Electronic medical records software - also referred to as EMR medical software - is a computerized medical record created a health care provider or organization like a hospital or doctors office. The electronic medical records software allows computerized medical records to be created, stored, queried, and shared by the health care organization.
The electronic medical records typically include patient diagnosis and treatment, physician notes, digital copies of x-rays, lab results prescriptions, or insurance information. Some EMR software applications can interface with electronic medical billing software so these records can be linked to the billing information. The EMR is helpful to the medical billing specialist in looking up provider notes to verify correct codes, dates of service, view copies of insurance cards and address, etc.
The basic look and feel and functions of most medical claim software and EMR software is fairly intuitive - once you learn one you can quickly learn another. However the capabilities of these programs can be overwhelming for the inexperienced medical billing specialist. These are basically tools for the medical billing specialist to manage, view, and organize patient records and claim information. Having good data entry and typing skills makes you to much more productive in medical billing and coding jobs.
Having good technologies empowers you as an employee and makes you more valuable to your employer. Here are some useful technology skills for medical billing and coding jobs:
Medical Billing Guidelines
It's also important for a medical billing specialist to be familiar with the guidelines established by HIPAA to protect patient privacy and the OIG guidelines to prevent fraud.
Challenges Operating a Billing Service
This is my rant on the challenges of operating a physicians billing service. This billing services owner shares her thoughts on the demands and challenges in working with doctors and their medical office staff.
What Is Medical Billing Fraud?
Medical billing fraud contributes to rising health care costs for all of us. It’s any attempt to fraudulently obtain payment from and insurance carrier. Medicare and Medicaid are especially susceptible to fraud due to their payment arrangement.
ICD-9 Diagnosis Codes
Find out what ICD 9 codes are and their relationship to CPT codes. What are the best ICD-9 codes reference for the medical billing and coding specialist.
CPT Medical Billing Codes
Find out what CPT Medical Billing Codes are and their relationship to ICD-9 codes. What are the best references for the medical billing and coding specialist.
CPT Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered.
Health Insurance Providers
Here's a description of the many different health insurance providers and health insurance plans available.
Dental Insurance Billing
Dental Billing - How it differs from Medical Billing. The same principles apply to dental billing insurance as with medical billing.
Working for A Billing Service
Learn what its like to work at a medical insurance billing services company. Here's an idea of what to expect based on my experiences both working for and owning and operating a medical billing company. This can be a great start for those looking for entry level medical billing jobs. That’s how I got started in this business.
Certification in Medical Billing
More details on certification for medical billing. The four organizations that offer certification, what it costs, and the requirement forgetting certified.
Medical Billing Training
Becoming a successful medical billing specialist, whether getting a job or starting a business, requires training in the fundamentals of medical billing. One of the best and most economical options is MedicalBillingCourse.com.
They are Better Business Bureau accredited, offer nationally recognized certification, taught by medical billing professionals, and have a 100% satisfaction guarantee. Check out their course outline here.
Considering Starting A Medical Billing Business?
Starting a medical billing coding business requires wearing several hats. What to consider when starting a medical billing service business. Links to other helpful resources.
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