Medical Billing as a Profession
A medical biller is not a medical coder, but a medical biller might need basic
medical coding knowledge, since both disciplines are so closely related and co-dependent.
We can't discuss medical coding unless we also speak about medical
billing, so closely are these two tied in with each other. Both discipline's goal is to assure that
medical reimbursement claims are promptly processed and submitted to health insurance carriers, and the health care
provider and facility gets paid for medical services rendered.
A Medical Biller Is...
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. As the saying goes: A medical biller is the provider's key to getting paid!" In
order for the doctor's medical practice, clinic, or hospital to prosper the medical biller must know the concept of
a clearinghouse and an A/R, and understand how to verify insurance coverage, determine eligibility, collect data,
submit all claims, avoid denials, contact patients and communicate with insurance companies to ensure the highest
possible return of revenue for their employer, or client.
There are over 819,000 physicians and surgeons, 2.4 million registered
nurses, 77,000 occupational therapists, 182,000 physical therapists, 94,000 respiratory therapists and
thousands of other allied health professionals in America's hospitals alone.
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 therapists,
podiatrists, dentists, etc.; hospital billing involves claims for inpatient services, which, in turn is different
from ambulatory emergency services for people who were treated in the ER, but not admitted to the hospital's
What are Billable Health care Costs?
The biggest segment of health care cost and expenses comes in form of bandages, prostheses, devices, implants,
medications, equipment, apparatuses, and countless other items required for modern care. These items and the
services associated with them must be properly coded and billed to the patient, or their health insurance provider
for reimbursement. This also includes wound care, and hospital stays. Understanding the reason for an insurance
company's claim denial is very important.
Submitting Medical Claims
Submitting medical claims is just as diverse as any other job. The medical biller must know the claims
processing guidelines for common health care plans, such as Blue Cross/Blue Shield, Tricare, Medicare and Medicaid,
etc, and state regulations that apply. There are three basic areas for billing:
- inpatient hospital
- outpatient services
- physician billing
This goes along with other sub-areas of specialized billing, such as for DME (durable medical equipment), and
for home health care, these are the three areas most entry level medical billers are expected to handle.
Do Medical Billers Code?
A medical biller with enough medical coding knowledge is certainly capable of verifying
that medical codes are used correctly, however, the initial medical coding process is not
necessarily their forte. Why? Because often they are not specifically trained in medical coding. If they
attempt to do it anyway and something goes wrong it can create liability for them. The medical biller's
strength lies in their knowledge of different health insurance plans, provider contracts, state rules and
regulations and getting denied claims overturned and paid when the denial was incorrect. Of course,
experienced medical billers with enough general knowledge of the medical coding process are
certainly allowed to handle the medical coding and billing process from start to finish.
- Medical Billing vs. Medical Coding
- Medical Biller Training & Schools for Medical Billers
- Medical Biller's Work and Medical Biller Duties
- Medical Billing Future and Professional Outlook