So, You Want To Be a Medical Biller And Start Your Own Services From Home?

Is Medical Coding The Same As Billing?

We can't discuss medical coding unless we also speak about medical billing; so closely are they tied in with each other! Both profession's goal is to assure that the health care provider and facility gets paid for medical services rendered.

Put Your Success Within Reach!!!
Certification is very important step. NHA offers two paths toward certification: the NHA National Certification Exam and their Home Study Certification Program for experienced medical coders and billers.

Medical Billing Areas

The medical biller must know the claims processing guidelines for common healthcare plans, such as Blue Cross/Blue Shield, Tricare, Medicare and Medicaid, etc. There are three basic areas for billing:

• inpatient hospital 
• outpatient services 
• physician billing 

along with other sub-areas of specialized billing, such as DME (durable medical equipment) and home health care. These are the areas most entry level medical billers start out with.

Medical Insurance Claims

The medical biller is often described as a medical practice's income manager and thought of as the doctor's key to getting paid. That's because medical office insurance billing services, also referred to medical claims, are just as diverse as those in medical coding. In order for the business so succeed financially the medical biller must understand how to properly submit all claims to get paid, and avoid denials, and fraud chages.

Different Types of Billing

Medical billing for facility-based providers is different from billing for non-facility based providers; just like inpatient coding is different from outpatient coding. Health care provider billing involves submitting claims for individuals, such as physicians, chiropractors, nurse practitioners, physical therapist and podiatrists, etc.; hospital billing involves claims for inpatient services, which, in turn is different from ambulatory emergency services.

Medical Insurance

There are many basic and major medical coverage plans, such as the Fee-for-Service Plans, Health Maintenance Organizations (HMOs), Point-of-Service Plans (POS) and Preferred Provider Organizations (PPOs), and many different methods of billing patients and insurance companies! Making decisions to achieve optimal reimbursements should always best be handled by an experienced medical biller.

Payment and Insurance Plans

Medical billers must understand all aspects of common health care and medical insurance options, including the different plans, carrier requirements, and state and federal regulations. It is also essential that they are able to find and pinpoint relevant information from source documents so that all claims for care and procedures are properly processed.

Examples

Allowable: The amount that is paid to the provider by the insurance is known as an allowable. For example, although a psychiatrist may charge $80.00 for a medication management session, the insurance may only allow $50.00, so a $30 reduction would be assessed.

Copayment: The insurance payment is further reduced if the patient has a copay, deductible, or a coinsurance. If the patient in the previous example had a $5.00 copay, the doctor would be paid $45 by the insurance. The doctor is then responsible for collecting the out-of-pocket copay from the patient.

Deductible: If the patient had a $500.00 deductible, the patient would have to pay the contracted rate of $50 ten times until the deductible was met, at which point the insurance would begin to cover a portion of the charge.

Coinsurance: A coinsurance is a percentage of the allowed amount that the patient must pay. It is most often applied to surgical and/or diagnostic procedures. Using the above example, a coinsurance of 20% would have the patient owing $10 and the insurance company owing $40.

(Text in the above paragraph is available under the terms of the GNU Free Documentation License.)