Medical Billing Specialist Duties & Billing Process. 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. Exactly what is medical billing? Sponsored content(1. Reviewsdrchrono EHR is a patient care platform that offers customization at the point of care and on the go. In addition to EHR, drchrono also includes scheduling, billing and patient reminders. It is available on i. · Fourth, health care reform will make connectivity, electronic medical records, and transparency commonplace in health care. This means that in several. Carrick Capital Partners is the private equity company of choice if you want to invest more than capital. Number: 0244 (Replaces CPB 331) Policy. Aetna considers the following products for wound care medically necessary according to the criteria indicated below. However, most of the innovations that healthcare leaders say they are excited about have less to do with medical advances and more to do with improving how health. Pad, i. Phone and Apple Watch. Healthcare.. Read More. Here we describe the medical billing claim process in detail and the typical duties of the medical billing and coding 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. Submitting Claims. 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.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.Responsibilities of a Medical Billing Specialist.In summary, here's the most common responsibilities of the medical billing specialist job description: Collect all the information necessary to prepare insurance claims and bill patients.Enter patient demographic and insurance information into the medical claim software. How To Crack The Intelligence Bureau Exam Result . Enter patient encounter information. Medical billing codes. Interpret and process (post) Explanation of Benefits (EOB's). Research, correct, and re- submit rejected and denied claims. Bill patients for their responsible portions. Answer patient questions regarding charges. Prepare appeals to denied claims. Understand Copays, Coinsurance, & Deductibles. Medical billing specialists need to be: Detailed oriented. Good with math and data entry. Knowledgeable on the insurance process, medical terminology, and coding. Familiar with medical billing guidelines. Trustworthy. Have good multi- tasking skills. Traits 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- 1. 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. Payment Processing. 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 $1. The insurer may pay an allowable amount of only $8. The $2. 0 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 $8. The patient pays the $2. If the patient had a $2. Additional provider charges after the $2. 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 $1. 00 allowable amount, the patient would be responsible for $2. 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: Timely Filing - How long after the date of service a provider has to submit a claim. Take Backs - Money already paid to a provider. This is for situations where a claim was mistakenly paid twice, paying for a patient that was no longer covered, etc. The process of appealing a claim that has been rejected. Any discounts. Procedures or treatments not included in the fee schedule. Payer contracts may be difficult to read and understand so don't be afraid to ask your provider or the insurance company for clarification. Facilities Served. 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: Individual healthcare providers. Clinics. Hospitals. Durable Medical Equipment providers. Billing Services. Medical Research and Education facilities. Hospice providers. Insurance companies. Physical, Occupational, & Speech Therapy providers or clinics. Nursing Homes. Ambulatory surgical centers. Mental Health providers. Home health agencies. Medical Insurance Billing Software Examples. What is revenue cycle management (RCM)? Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance. By submitting your personal information, you agree that Tech. Target and its partners may contact you regarding relevant content, products and special offers. You also agree that your personal information may be transferred and processed in the United States, and that you have read and agree to the Terms of Use and the Privacy Policy. RCM unifies the business and clinical sides of healthcare by coupling administrative data, such as a patient's name, insurance provider and other personal information, with the treatment a patient receives and their healthcare data. Communicating with health insurance companies is a key component of RCM. When a patient schedules an appointment, the physician's office or the hospital staff typically check the patient's reported insurance coverage before the visit. After an insured patient receives treatment for a given condition and supplies any applicable copayment, a healthcare provider or coder categorizes the nature of the treatment according to ICD- 1. The hospital or care facility then sends the care summary with ICD and Current Procedural Technology codes to the patient's insurance company to see what portion of the care will be covered by insurance, with the patient billed for the remainder. Revenue cycle. The revenue cycle includes all the administrative and clinical functions that contribute to the capture, management and collection of patient service revenue, according to the Healthcare Financial Management Association (HFMA). Here is what's involved in the revenue cycle: Charge capture: Rendering medical services into billable charges. Claim submission: Submitting claims of billable fees to insurance companies. Coding: Properly coding diagnoses and procedures. Patient collections: Determining patient balances and collecting payments. Preregistration: Collecting preregistration information, such as insurance coverage, before a patient arrives for inpatient or outpatient procedures. Registration: Collecting subsequent patient information during registration to establish a medical record number and meet various regulatory, financial and clinical requirements. Remittance processing: Applying or rejecting payments through remittance processing. Third- party follow up: Collecting payments from third- party insurers. Utilization review: Examining the necessity of medical services. Factors that affect the revenue cycle. As with any financial matters, there are internal and external factors that affect how revenue is collected. A healthcare organization can exert some control over internal dynamics, such as provider productivity, patient volume and fees for services. However, it is more difficult to influence external factors, such as patient payments or claims reviews from insurance companies. Revenue cycle management systems. Healthcare providers often purchase and deploy designated revenue cycle management systems to store and manage patients' billing records. An effective RCM system can reduce the amount of time between providing a service and receiving payment by interacting with other health IT systems - - such as electronic health record (EHR) and medical billing systems - - as patients move through the care process. An RCM system can also save healthcare organizations time by automating duties that were previously handled by employees. These duties include administrative tasks, such as informing patients of upcoming appointments, reminding payers and patients of an existing balance and reaching out to insurers with specific questions when a claim is denied. RCM systems can also save providers money by giving them insight into why claims have been denied. Specifically, an RCM system can cut down on denied claims by prompting healthcare employees to enter all the information required for claims processing. This saves them from having to revise or resubmit the claim and gives providers better insight into why certain claims have been denied, thereby enabling them to rectify the issue. This also ensures that providers are reimbursed properly for taking care of Medicare patients. An organization can purchase data analytics software and use dashboards to set and monitor revenue goals. The organization can visualize where its revenue cycle has room for improvement by sorting billing data and by producing corresponding reports. Revenue cycle management systems now also include technologies such as cognitive computing to help ensure the correct medical codes are assigned to the correct patient, and robotic process automation to help speed up the process. RCM and value- based care. Some experts believe that RCM systems will also ultimately help transition the industry over from fee- for- service to value- based reimbursement. The analytics involved in many of these RCM systems allow payers and providers to get a more detailed look at their patient population, such as what portion of their patient population is suffering from which chronic diseases, as well as allowing them to monitor the claims data and pinpoint any abnormalities. This is particularly important given the Medicare Access and CHIP Reauthorization Act of 2. MACRA), a piece of recent legislation pushing healthcare towards value- based care and value- based reimbursement. RCM vendors and key organizations. Prominent vendors that sell either stand- alone products or RCM systems integrated with EHR systems include: Mc. Kesson - one of the largest providers of medicines, pharmaceutical supplies and health IT products and services in the United States. Cerner - a company that provides various health information technologies ranging from medical devices to EHR to hardware. GE Healthcare - a subsidiary of General Electric Co. IT such as more advanced medical imaging technology and patient monitoring systems. ADP - a global business outsourcing services provider and one of the largest payroll outsourcing providers in the world. Epic Systems - one of the largest providers of health IT, used primarily by large U. S. hospitals and health systems to access, organize, store and share patient medical records. Allscripts - develops and sells software and services to various types of health care providers. EHR systems for small to medium- sized physician practices and hospitals. Dell EMC - an American multinational technology company that offers products and services across all areas of computing, networking and storage. Greenway Health. Meditech - sells health IT used in 2,4. U. S., Canada and United Kingdom. In addition to these vendors, another key player in the healthcare revenue cycle services space is the HFMA, a nonprofit organization that advocates for healthcare finance professionals and promotes related standards and practices.
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