Medical Billing Knowledge and Training

Training for medical billers comes in a wide variety, from on the job training, home study distance education programs, technical school diplomas, to full college course of studies and degrees. Credible training takes weeks of theoretic and hands-on instruction by qualified instructors to cover medical billing procedures, medical coding routines, medical terminology, introduction to anatomy and disease processes, medical office administration, data entry, word processing and computer skills.

Typical Medical Billing Training Requirements

While presently there are no specific educational or certification requirements for medical billers and coders clinical managers and directors have established their own policies and expectations of how they evaluate and hire job applicants for their departments.

Those interested in an office manager position might need additional training and strong experience in a specific clinical area, since, for example, the director of a physical therapy clinic might expect that their medical coder is experienced in physical therapy. Those who intend to cross train into other higher level positions such as in Health Information Management (HIM) might need a bachelor's degree in health information, or medical record administration in order to qualify.

Medical billing students are trained 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 code modifiers
• Regulatory compliance
• The CMS 1500 Form
• How to read and understand an EOB, EOMB and remittance
• Medicaid billing and appeals process
• Tricare, Veterans Administration (VA), 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 health care
• 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.