6 Traits of a Successful Medical Insurance Specialist

From my experience working as a medical insurance specialist, I thought about what the characteristics are of people who are successful in this field. If I was going to hire someone, what traits would I look for?

So we’ve come up with 5 traits that you will find from any successful medical billing specialist:

1. Results Driven

The results of the medical insurance specialist are easily measured just by running a report in the practice management software. But a poor report doesn’t mean the medical billing specialist is doing a bad job. It may very well be that claims are being rejected due to incorrect coding, poor front office practices, or just a lack of cooperation from the provider. Most medical billers I know genuinely want to do a good job and get a great deal of satisfaction in seeing a practice do well because the billing is going smoothly.

So if you are a provider or manager of a billing office the fact that claims are not getting paid is usually the symptom and not the disease. It’s important to find the root cause of why claims don’t get paid and implement processed to close those gaps. Just ask the billing specialist. They know the process best and where the problems are and just need the support and cooperation of everyone to make it happen.

2. Follows Up On Unpaid Claims

Being diligent about unpaid or rejected claims is critical to successful billing. The longer a claim goes unpaid, the more likely it is to not get paid at all. And with the different policies and contracts of each insurance company, it’s important for the medical insurance specialist to have a good understanding of the unique requirements of each payer and how to resolve issues with them. Most Blue Cross organizations have a representative available for providers and their staff who can investigate claim issues from their end and help you to resolve troubled claims. For a large practice there can be a lot of claims with “issues” that need to be resolved in order for them to get paid. A good medical insurance specialist has a system for tracking and prioritizing these claims until they are resolved.

3. Stays Abreast of Current Topics

Regulatory or legislative changes that affect healthcare are a way of life. And many of these affect billing and coding. The best example would be the HIPAA Act (Health Insurance Portability and Accountability). Even though this legislation was passed back in 1996, we’re still seeing it’s implementation several years later. For example the adoption of ICD-10 codes in 2014 is a requirement of HIPAA. This will have a significant impact on the coding and billing functions. Before that was NPI (National Provider Identifier) requirements which affected software programs and the forms used to submit claims - the CMS-1500.

The point is that it’s important for billers and coders to be informed on these changes and understand how they affect the practice. Not being in compliance can result in fines and liabilities for their employer and interrupt the processing and payment of claims.




4. Is Patient

Being an effective medical insurance specialist requires a lot of communication with a variety of entities. From providers to insurance companies to patients. With insurance companies there can be a lot of back-and-forth phone calls and voicemails. Some insurance companies don’t always make it easy to get claim issues resolved. This requires patience. It’s especially true when dealing with Medicare or government agencies.

Patience is also required in dealing with physicians. Many doctors have a tremendous amount of responsibilities in their jobs. They may not always be accessible for the biller or coder to get their questions answered - at least not immediately. And answering some questions likely requires going back through the patients files. If you’ve ever seen what a doctor has to do through the course of their day you can understand.

There may also be times when the medical biller has to deal with a disgruntled patient because of a billing problem. You have to remember when there are issues with a patient's insurance coverage - or lack of it - they usually take it out on the provider and their staff first - even though the provider is simply filing claims on their behalf. They may have to be reminded politely that they are no longer covered by their policy - or that they have a higher deductible than they thought. Many times the insurance information they provided is not correct. So being patient and diplomatic when dealing with these issues is also a desirable trait.


5. Understands Insurance Payer Contracts

A big part of a medical insurance specialist's efforts is to understand and comply with the various insurance payer's contracts. These contracts the provider negotiates with the insurance company specify important terms for getting paid. They also include requirements for when claims must be files after a patient encounter, how to appeal rejected claims, and special situations involving costly procedures or supplies.

If the biller doesn't understand and comply with the payer contract terms then the claims may never be paid because they missed an opportunity. That's why it's important to keep on top of insurance company requirements and let your provider know if you need important information to resubmit a claim. It's also important to be persistent with insurance companies. There are sometimes situations where the insurance payer should be challenged when a claim or appeal is denied.

6. Is Appreciated

Last but certainly not least. If you are a provider please show your biller how much you appreciate them. And listen when they bring up issues. They can be the “Canary in the coal mine” when it comes to the financial health of your practice.  It’s important to remember the regular changes introduced by HIPAA and other regulations, the medical biller is the one who many times gets the brunt of it. Because no matter how hard you work, if the biller isn’t able to get the revenue coming in, it won’t matter how hard or long you work.

Any employee’s performance suffers when they don’t feel appreciated, and this is especially true with medical billers. Because what they do is viewed as a “back office” function, there’s the perception that it’s not as important as the clinical staff’s jobs.

Showing appreciation and gratitude to the medical insurance specialist can go a long way towards improving the financial performance of the practice.




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