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Industries & Professions /
Medical Billing Service Owners
No matter how many injuries or illnesses you may have had in high school, you probably have not had much experience with insurance companies. Your parents, however, have certainly dealt with the responsibilities of maintaining insurance coverage for the family. They have saved bills, submitted claims, and dealt with doctors' offices and insurance agencies. Health care coverage is considered an important and necessary benefit of full-time employment, so much so that many people make job decisions based on the quality of insurance available. Insurance has become a major concern as people struggle to meet the rising costs of health care.
So you can imagine the difficulties facing doctors in billing patients, filing claims, and keeping accurate patient accounts. In addition to private insurance companies, doctors receive payment from Medicare (a government insurance program for people over the age of 65, and for people with disabilities), Medicaid (a government insurance program for people of all ages within certain income limits), and workers' compensation (insurance from employers to cover employees injured on the job). In order to get paid by these insurers, doctors must submit detailed claims. These claims include information about diagnosis and treatment, and require knowledge of medical codes.
Medical billers handle the filing of these claims. They work out of their homes or offices, and take on as many clients as they choose. Many medical billers have three or fewer clients. Medical billing is often seen as supplementary income, and more than three clients may require a staff and much more time.
One of the main responsibilities of medical billers is to convert the doctor's diagnosis to a special medical code. Medical billers use International Classification of Diseases (ICD) codes that represent diagnoses, and Current Procedural Terminology (CPT) codes that represent treatment procedures. These codes are standard for private insurers across the country, and for Medicare. Medical billers typically consult a book of codes in order to determine the correct code for the procedure. This can be challenging at times because there are detailed codes for medical procedures and conditions. For example, there are about 100 codes for pneumonia, and insurers require precision in regard to which ones are used. Once the biller has the correct code, he or she can file a claim.
All insurance companies, including Medicare and Medicaid, now require claims be submitted electronically. Electronic claims have proven cheaper than paper billing, and they speed up processing by several weeks. Many medical billing service owners use a software system called Medical Office Management Systems, which is designed specifically for medical billing. After getting online, the biller obtains the physician's National Provider Identifier Standard number (used to identify the physician when billing Medicare, Medicaid, or other insurance), place of service, the ICD code (used when billing for services), the CPT code (used when billing for services), and the cost of the visit, and electronically submits this claim to a clearinghouse. A clearinghouse is a service that routes the claims to both the primary and secondary insurers. Payment goes directly from the insurer to the doctor, so the medical biller must check with the doctor's office to keep track of paid claims.
Medical billing doesn't just involve computers. There are many phone calls to insurers and doctors to make sure that diagnoses are correctly coded and claims are paid. The medical biller must also speak to family members of patients to determine how deductibles are to be met.
Some medical billers handle only insurance claims, while others offer many services. They may also send bills to individual patients. They may deal with insurance companies for clients, following up on claims. Medical billers also have to maintain their own financial records, such as business expenses for tax purposes, and payment received from doctors.