Medical billing involves the submission of medical claims for each covered patient to an insurance company. Medical billing specialists work in an office or they work from home, but they use the basic billing practices and procedures of general accounting, as well as accounting skills designed specifically for medical billing.
Patient Records
The medical billing specialist is solely responsible for maintaining the doctor's office or hospital's patient accounting records for coding, billing and for payment purposes when or at the time that treatment is received.
Medical Coding
Medical bills have special codes, called Level I and Level II HCPCS (Healthcare Common Procedure Coding System), ICD-9 (International Statistical Classification of Diseases and Related Health Problems), ICD-9-CM (International Statistical Classification of Diseases and Related Health Problems, Clinical Modification), and CPT (Current Procedural Terminology) codes, to help the insurance company determine what the service was for, whether or not it was necessary according to the doctor's diagnosis, whether or not the treatment was necessary, and whether or not the service is covered or will pay out, and for how much of the covered claimed amount. There are other billing service-code types, but these are the major ones that are used and offered during medical billing training classes.
Types of Medical Bills
There are different types of medical bills, codes and claims according to which carrier the patient uses, what kind of insurance coverage they have, and what the stipulations are for submitting the claim. Basically, billed claims that are submitted for payment include those for managed care, such as PPOs (preferred provider organizations), HMOs (health maintenance organizations), POSs (point or plan of service), traditional and indemnity claims (the usual 90/10, 80/20, or 70/30 insurance coverage plans), Medicare or Medicaid (government assistance plans); supplemental coverage (secondary billing), hospital billing (facilities claims), labs (testing or x-rays, etc.), or subrogation (i.e., third-party liability) billing claims. These are coded and billed according to type of claim, in accordance with the doctor's overall diagnosis.
Minimum Knowledge for a Medical Billing Specialist
At minimum, a medical billing specialist must know medical terminology, color-code office files, how the filing system works, where to find key medical information needed to code a bill for submission for payment, ask the doctor or nurse when he is uncertain code a claim for payment, and the best practices to use to keep a claim from being denied when submitted to the patient's insurance company.
Medical Claims
Claims are the billing sheets that are sent to insurance companies to request payment for a service rendered or treatment received while visiting a doctor's office, hospital or ancillary facility. Medical billing specialists must know the codes listed in Part 2 above, because the better they are at using them on claims, the more of a chance there is that payment will not be denied in full or at least paid in part. Coders and billers often do the same job in smaller offices and facilities, but there are jobs in larger companies or corporations where the two positions are totally separate.
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