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Medical Billing Knowledge and Training

Medical billing personnel must have a basic understanding and training in the following areas:

• Medical Anatomy and Physiology
• Medical Terminology
• Insurance Terminology
• Documentation Standards (1995 or 1997 E/M Documentation Guidelines)
• Current Procedural Terminology (CPT)
• International Classification of Disease (ICD)
• Use of Modifiers
• Regulatory Compliance
• The CMS 1500 Form
• How to read and understand an EOB, EOMB, and Remittance
• Medicare Billing and Appeals Process
• Medicaid Billing and Appeals Process
• Tricare, Veterans Administration, Federal Employees, and CHAMPVA billing
• Private Health Insurance such as PPO, HMO, POS, and Traditional Policies
• Workers Compensation Claims Requirements
• Personal Injury Claims Requirements
• The Patient’s Benefit Manual and Patient’s Requirements for Claims and Appeals
• Coordination of Benefits
• Federal Laws such as ERISA, Stark, Anti-Kickback and False Claims
• State Laws regarding Insurance, HMO, Timely Filing, Refunds, Balance Billing, PIP,
   Medical Records, Debt Collection, Workers Compensation, Prisoner healthcare, and
   Medical Terminology.
• The provider insurance contracts
• Processing Payments, Appealing denials, Processing demands for claims information.
• Accounts receivables.

Patient Calls and Complaints

Medical coding professionals must also be trained in customer service and proper telephone etiquette, since patients often call the doctor's office when their health insurance company did not pay a claim. Some claim denials can happen when the patient no longer was covered due to departing the employer with no COBRA coverage. Often the patient do not want to pay the premiums themselves, and question the charge.

• The denial could be due to the patient obtaining health insurance but it did not go into effect on the date of service.
• Sometimes a patient gives an insurance policy that was terminated but the insurance company paid the claim anyway, and now years later, the insurance company says they want their money back.
• Or, the denial could be simply because the medical care was not a benefit that the patient was entitled to receive. Their contract with their insurance company may have time limits.

Remember: Patients that feel they are now "stuck" with the medical bill for their care often are upset and may not always remain calm! When they question the charges, and wonder whether there are errors, or associated charges their insurance should have paid, the medical billing staff must be able control the intensity, and explain these entries understandably and completely. At the same time they must remain calm, assertive, and empathetic toward the caller.