Medical billing happens anytime a patient receives services or products from a provider. This ranges from an office visit with a medical provider, to surgery, to obtaining durable medical equipment such as a wheelchair. When any of these medical events happen, the patient and their insurance are responsible for reimbursing the provider of these services or products. The Medical Biller is the person who makes sure this happens. A good Medical Biller makes sure their provider is reimbursed the maximum amount possible by using their knowledge of the insurance rules and regulations.
It would not be easy to automate the Medical Biller’s job. Their job ranges from interpreting the physicians notes and records to verifying and correcting patient and insurance information, to correcting coding, to making sure maximum reimbursement happens.
To pull all of this information together is just the beginning as that gets the claim filed. Then the claim has to go through the adjudication process! Once the claim is processed and paid or denied, then the Medical Biller must interpret payer coding error messages to make sure the reimbursement is correct or to facilitate resubmitting a denied claim for successful payment.
Another term for a Medical Biller is an Insurance Billing Specialist as much of their time is spent dealing with the ever-changing insurance rules and regulations to get the payment for their provider. These rules and regulations are not only put into play by the insurance carrier themselves.
The insurance company must also follow all government rules such as those imposed by the Centers for Medicare and Medicaid Services (CMS) Insurance can be very frustrating to deal with, so patience is not just a virtue, it is a necessity.
There are several hats worn by a biller who owns their own business, or a Medical Biller in a small provider’s office:
These roles are typically broken up separately in a larger company.
The lifecycle for a typical Medical Biller (or billing team) looks something like this:
Terminology to Help the Medical Biller
When you become a Medical Biller, you must learn to speak a new language. Here is a list of common terms that a Medical Biller must be able to use and understand:
Adjudication – Processing and payment of a medical claim by an insurance payer following their rules and regulations
Appeal – the process of challenging an insurance company refusing to pay a claim
Beneficiary – the patient who is covered by the insurance policy
Clearinghouse – the entity that forwards insurance claims to the payer on behalf of the provider after they have been filed. They often will do front-end edits to make sure the correct information is in the claim, however, they do NOT determine payment
Co-Pay – The amount of money the patient pays for each service
Co-Insurance – Percentage or flat rate the insurance determines the patient will pay
Coordination of Benefits (COB) – What happens when a patient has more than one insurance, determining which insurance is primary and billing them appropriately
Credentialing – the process for a provider to be recognized for payment by a payer
Crossover Claim – When a claim is paid by the primary payer and then automatically forwarded to the secondary payer
CMS-1500 – Form determined by the Centers for Medicare and Medicaid Services as the form to be used to submit claims to insurance companies for reimbursement
Day Sheet – Daily summary of charges, patient payments and insurance payments on a daily basis
Deductible – the amount a patient must pay before the insurance company will begin to pay
Fee Schedule – A list of the CPT/HCPCS codes used by a provider and their customary charges
Guarantor – Responsible party who is NOT a patient
In-Patient – a stay in the hospital of more than 24 hours
Insured – the person who actually carries the insurance
Modifier – a two-digit code that provides more information about a particular CPT/HCPCS code
Medical Necessity – the determination of whether a medical procedure or product is necessary for the patient
Medicare – Insurance provided for persons over 65 or other specific conditions such as End Stage Renal Disease (ESRD)
Medicaid – Insurance provided for low income persons
Payer – the health insurance paying the claims
Practice Management or Medical Billing Software – the software used to track patient traffic within the provider and/or to create the claims
Provider – A person or facility who provides medical services or products
Privacy Rule – HIPAA Regulations to protect the patient
Security Standard – Regulations to protect Patient Health Information (PHI)
Superbill – Customized document used by the provider to document services
Tricare – Insurance for active-duty military personnel and their families
Acronyms and Abbreviations to Help the Medical Biller
Along with terminology, a Medical Biller will be faced with many acronyms that they must become familiar with to do their job.
AMA – American Medical Association
BCBS – Blue Cross Blue Shield
CMS – Centers for Medicare and Medicaid Services
CPT – Common Procedural Terminology (a five-digit code used to define a provided procedure)
DME – Durable Medical Equipment
DOS – Date of Service
Dx – Abbreviation for diagnosis
EHR – Electronic Health Record
EOB – Explanation of Benefits
EMR – Electronic Medical Record
ERA – Electronic Remittance Advice
E/M – Evaluation and Management codes used in billing
HCPCS – Health Care Financing Administration Common Procedure Code Systems (pronounced hicks-picks)
HIPAA – Health Information Portability and Accountability Act – has to do with patient privacy
ICD – International Classification of Diseases
NOS – Not Otherwise Specified
NPI – National Provider Identifier
PHI – Protected Health Information
POS – Place of Service
RVU – Relative Value Units
SOF – Signature on File
This is just a brief overview of what you are looking at as a job when becoming a Medical Biller. It is very important that you have a good practice management or medical billing software to use. TotalMD has many advanced features that will assist you in obtaining payment for your provider. To schedule a demonstration of the product, please contact our Sales Department at 800-613-7597 Option 1 or click here.