What Is Medical Billing?

How I Got Started in Medical Billing

Many years ago, I was fortunate enough to accidentally discover something called “medical billing” because I happened to be in the right place at the right time. Little did I know, the accidental discovery would lead me to my true employment passion medical billing and coding. My prior employment history involved openings in food service and later retail. I felt both of these industries could be my calling and means of helping support my family. The problem I continued to be faced with was boredom and usually, after about a year at a position, I would begin looking for another place of employment.

My mother’s friend managed a data entry unit at a local healthcare organization. She advised my mother to send me to see her about a position in her unit. A person was needed to fill a temporary entry level position, posting patient payments received on an account (ROA) as well as copayments made at the time of service (TOS). I was offered this awesome position! A position I knew nothing about, in a field I never really knew existed.

I learned that this position was a part of the many departments and services involved in the medical billing process. The activity generally falls under a department known as Patient Financial Services or the Business Department. Little did I know at the time, I would soon learn I had found my employment playground! I have never experienced boredom at work since beginning my career in medical billing in October 1995 when I was hired as a data entry clerk. I was offered $6.50 per hour, my first job with health insurance, paid time off (PTO) and holiday pay! All of it was sweet, but the sweetest thing I encountered was the world of never ending learning. I have learned more than I could begin to explain and have only chipped away at the top of a very large mountain known as Medical Health Care employment.

Understanding a Typical Day in a Medical Office

You may believe that a face to face visit with a medical provider is a simple one or two step process involving a doctor, the office staff, and a health insurance company. My journey taught me very quickly this thought was a myth! Let’s begin with the typical steps starting with the initial telephone call to the doctor office to schedule an appointment.

The Patient’s Initial Appointment is Made

The appointment is generally scheduled by a member of the doctor’s front office staff. The final objective for the medical billing department is to submit a clean claim. This goal is one that involves many hands prior to becoming a claim. At the time of scheduling the appointment, the goal of the front desk staff is to obtain or verify all patient information which is known as the patient demographics (address, telephone number, date of birth) and health insurance information listed on the profile of the patient medical record.

The appointment is scheduled in the computer generally known as an electronic health record (EHR) or electronic medical record (EMR). This begins the initial steps of submitting a clean claim electronically. Due to the advancement of technology, medical claims are submitted electronically to an entity known as an electronic data interchange system (EDIS).
When a claim is submitted electronically, without any need for corrections, it is very likely the reimbursement (payment for services) would be deposited in the health organization’s bank within ten (10) business days or less. This is known as the reimbursement cycle. Medical billers are responsible for ensuring physicians are paid for the services performed. Sounds easy enough but many obstacles will try to interrupt the payment process. You will never cease to be amazed at what could occur to stop the process! A medical biller is responsible for clearing each hurdle, within a specified time to avoid losing the payment altogether.

Verification of Benefits, Copayments, Deductibles & Prior Authorizations

Once the patient appointment is scheduled, the activity begins. An office staff member or a medical biller may be responsible for verifying benefits. A simple process of verifying the health insurance information provided is correct, the policy is active, and the service is covered by the patient’s policy. A review of any copayment required, if there is a deductible, the amount if any the patient has satisfied and whether a prior authorization is needed. Many services require permission prior to the actual service or visit. In the past, prior authorizations were needed for surgery or minor office procedures. Now a day, this is another insurance service requirement being added to insignificant services which overburden the process of efficiently treating patients by a physician and being paid for those services.

Deeper Audit of the Patient’s Record for Payment History, SBA, Collection and Flags

The patient’s medical record may be audited including payment history for possible copayment credits or small balance adjustments (SBA) for past unpaid balances which would be reversed with intent to collect from the patient. A review of the payment history may determine how to proceed with any balances not paid, previous payment problems with a negative payment history, or past medical collection assignment(s). Any of these actions could create a need for a flagged account. Flagged accounts indicate something needs to stand out to the front office staff and indicates it is not a typical account. Flagged accounts could indicate returned mail due to a bad address, previous collection activity, lack of response to requests for payment or several other possibilities. A flagged account typically results in a visit from the medical billing department representative after you arrive for your appointment.

As a medical biller, I am amazed at the actions some patients go to, to avoid paying copayments. Most do not understand that legally a physician is obligated to collect the patient portion of the visit per the physician contract as well as the member’s obligation with their health insurance carrier. Recent actions to combat this issue by physicians has caused many to cancel a patient appointment at the time of the visit as well as installing ATM machines in the lobbies of medical facilities. It is not uncommon for a patient to have a copayment of $25 or higher. The time and effort to try and obtain this money after the fact is very time consuming, expensive and does not always result in cooperation from the patient.

Appointment Day & The Front Desk Check-in Process

At the time of the patient’s appointment, a front desk team member begins by acknowledging the patient with a friendly greeting upon arrival to the office. The front desk representative will call the patient to the front desk, request any copayment due and conduct an overview of the medical record, verifying the patient demographics and health insurance information, updating as needed. In order to obtain our goal of submitting a clean claim, it is very important to have a front desk representative dedicated to detail while providing the highest level of integrity and customer service in order to meet the intended goal of a clean claim.

Date of Service (DOS) and Initial Encounter

The activity at the front desk begins the data capturing process with the appointment known as the date of service (DOS) attached to the physician’s face to face visit with the patient. The patient is sent to the Medical Assistant (MA) who adds additional information to the patient medical record, i.e. weight, height, blood pressure reading and the standard measurements performed for office visits. The patient is placed in an examination room until the physician presents and begins the appointment process. The physician will discuss any concerns with the patient while recording the patient’s responses into the EHR system creating the visit/encounter or chart note.

SOAP Note

In order to reach our goal of submitting a clean claim, the physician will create a SOAP note. The SOAP note includes details pertaining to the SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN. The information derived from the examination will create the necessary details needed to determine the medical necessity. The subjective information, (what the patient states) to the physician about the reason for the visit and is recorded. The Objective portion, (the physician’s observations and findings) during the examination is also entered into the health record. The subjective and objective categories will lead the physician to his assessment (what the symptoms are indicating) of the visit and his plan (how to proceed with treatment) to help the patient.

Chart Notes and Locking the Encounter

To finalize a patient’s encounter, the physician will need to complete the chart note and/or operative report (dictation) and prepare to close the visit. The provider’s electronic signature is the action that locks the date of service notes in the electronic health record. It is a legal requirement and signifies the medical record for the encounter is accurate and complete. If an occasion presents a need to correct, update or clarify any information it must be done in a compliant manner (legal or obedient processes) as outlined in the organization’s procedures of obligation to protect medical data and its authenticity. Each organization is legally responsible for creating a written compliance process of procedures that must be followed to avoid fraudulent changes. Medical staffs, including physicians, are not allowed to “just” change notes, especially in situations to appease patients who are determined by their own insurance carrier to be financially responsible. As a medical biller, you will certainly be the staff member who is placed between a complaining patient and a physician! You will learn to navigate this duty in a manner that is ethical to your occupation.

Still Using Paper? No Problem. Use Encounter Forms or Superbills

If the provider is not using an electronic health record and still uses paper charts, the process outlined above is much the same. When a physician is not using the electronic health record, the patient visit would be recorded on an “encounter form” or a “superbill”. A superbill is an itemized invoice of the service(s) performed (procedure codes) and the reason (diagnosis codes) the service was needed. If a superbill is used, it generally has the top procedures (CPT codes) performed in the office listed as well as other services. Some sections of the superbill allow for written information i.e. diagnosis codes; return appointment information and other pertinent details to the front office or other departments. Encounter forms/superbills are going out very quickly…..this method requires additional steps the EHR/EMR does not. The first step would be to have an employee (data entry clerk) enter (data entry) all the information needed i.e. insurance details, CPT/diagnosis code (dx), patient demographics and health insurance details into the billing system and later printed on a paper claim for a mailed submission to the health insurance carrier. The EHR/EMR is a direct billing system used to enter data by the physicians, medical assistants, nurses and other medical personnel as allowed by law. As you can see, there are several steps involved prior to preparing a medical claim form to bill charges for payment.

The Medical Biller’s Work Starts Here

Now the medical biller’s responsibilities begin. It is hard to describe a typical day in the medical billing office or even of a medical biller. I will begin by saying my days never seem typical. You may have a mental plan for your day laid out in your head but depending on many other factors, including the specific date of the month, plans change!

About the First Days of the Month and the Month End Process

For example, if it is the first few days of a new month, you more than likely just completed the month end process or closing of the books (reconciliation of all charges, payments, and adjustments) to determine the days in A/R (length of time to obtain accounts receivable). In the medical billing world, this is a big deal, particularly for management. If the days are not in an acceptable range, management is responsible for explaining to the Chief Officers what the problem is. In return, the Chief Officers are responsible for explaining to the physician’s why the account receivable files increased. Keep in mind, the closer it gets to “month end” the more stressful the medical billing department becomes ………Month end was always a favorite time for me. I knew I could count on perks like overtime to assure the month end deadline was met with success. I would also be loaned out to other departments to assist with duties related to month end. Month end is one of the main activities I was able to increase my knowledge, skills, and value to the organization.

How the Medical Billing Workload is Divided

Next, let’s move on to some of the methods used to divide of the workload. Generally, the billing department has a method of who is responsible for which accounts. Patient accounts could be divided by alphabet with person A working all patient accounts with last names in the A-F range, next person B would have G-N and so on. Or maybe the accounts are assigned to billers based on the insurance carrier. One person could be responsible for The Blues which would be all Blue Cross or Blue Shield; another person could be assigned all government insurances Medicare, Medi-cal, Tricare and so on. My preferred method is being employed by a company that allows the medical biller to work accounts from start to finish. This method means the medical biller would be responsible for all aspects of the account until the balance is zero or transferred to collections.

Getting Your “Dailies” Done

Let’s say it is the beginning of the month, maybe it’s a Monday or Tuesday morning and a classic example of my day would begin with doing my “dailies”. Dailies are the items a billing department or biller is responsible for doing each day. Not all members of a department have dailies. Other responsibilities are divided or assigned to complete throughout the day in addition to your regular duties. If you are a solid, dependable employee who requires little supervision you would be given dailies.

Cleaning Edits

Some of the dailies I worked included reporting the number of claims and the total dollar amount for each health insurance carrier electronically billed the day before to my supervisor. I was responsible for cleaning edits (correcting pre-billing errors). The process of cleaning edits would begin with a report indicating which patient accounts would not allow a claim to be billed due to errors identified by the internal billing system.

Edits are corrections needed to areas like an incorrectly linked diagnosis. For example, the patient’s insurance is being billed for an office visit and a pregnancy test. The registration process indicated a female patient but the front desk representative selected the gender “male”. The computer system understands a male is not likely to need a pregnancy test and kicks the claim out of the process to be reviewed by a human for correction. I would correct the information and re-cue (resubmit for billing) the corrected medical claim for reimbursement.

Edits can occur for a number of reasons. There are some days with very few edits to review and correct. Then there are other occasions when several edits appear for various reasons. An edit could relate to billing a terminated health insurance plan. Other edits could be in reference to changes made by the front desk staff i.e. transposing the member’s health insurance number, using an incorrect date of birth, listing the wrong subscriber of the policy or even something like billing the wrong health insurance. For example, if a patient has both Medicare and Medi-Cal but the insurance order was entered backward, i.e. Medi-Cal listed first (primary) and then Medicare (secondary); the system will kick the claim out for review. The system is programmed to know the correct order of billing these two government health care plans. Medi-Cal is always the last insurance billed per general billing guidelines. Remember, a clean claim is a goal to strive for.

Are you beginning to understand how the medical billing process is dependent upon everyone doing their best to focus on accurate steps when adding patient information necessary for billing to avoid reimbursement delays? Once the edits are cleaned, the claims are ready to be resubmitted.

Processing Returned Mail

Another daily may be processing returned mail. Patients move around and usually forget to notify the billing office of address updates. If patient mail is returned as undeliverable, a biller would research to try and find a valid current address. If no new address information is located, and the patient is not scheduled for a future visit, the account may be sent to a collection agency. Collection agencies have additional tools to locate new addresses or telephone numbers. The account is flagged as “RETURNED MAIL”. The flag categorizes the problem and brings everyone’s attention to the same issue for correction.

Returning Voicemails and Emails

Moving along with our morning, a billing department or a biller may also return voicemails and emails as part of the daily process. Generally, inquiries are followed up within 24 hours. I am one of those people who do not like playing telephone tag whether I am being a biller or just a person at home. I do my best to answer the telephone when it rings if possible. I have created many great relationships with patients, co-workers and vendors i.e. health insurance employees due to making myself available. It goes a long way with your reputation too. I will even provide my last name and my direct contact number to build trust. I want my calls answered and I try to give the same courtesy to my contacts and answer the telephone when it rings. More than likely some of the calls will require additional research and follow up with the patient. It is important to follow through to the end with patient assistance.

Additional Roles and Challenges Inside the Medical Billing Department

In the background of the medical billing department, other employees are working on a variety of tasks. Some are copying medical notes to submit to the health insurance company as requested. A few medical billers are on the telephone discussing claim status with health insurance representatives or assisting staff from the doctor’s office with questions. The medical billing department is bustling with activity. A billing member responsible for releasing claims for payment would be getting the information in order to release. A handful of medical billers may be posting payments received on an account (ROA). A team of medical billers is reviewing claims incorrectly denied payment which will require follow up for appeals or corrected claims.

Payment Poster and Collections

Duties could include posting charges (data entry) and posting payments to individual accounts. It might include preparing and sending statements to patients for any balance due, setting up payment plans or returning calls to patients with questions or complaints.

The best resolution would be an account paid in full (PIF) or for patients who are not willing to return calls or make payments, preparing the account for outside collections (hardcore collections). Doctors are not fond of sending patients to collections and many attempts are usually made to connect with patients to clear balances. The minimum standard is to send three statements and make at least one telephone call directly to the patient. It takes quite a bit of work to send an account to an outside collection agency. Once the account is turned over, the physician is usually looking at recouping approximately 50 – 75 % of the original amount owed.

The Appeals Process and Coordinating with Insurance Carriers

This is not an all-inclusive list of what is going on in a billing office by medical billers. Each unpaid claim after a set amount of time may require research and communication with the insurance carrier to find out why a payment was not received. It may be delayed due to additional requests for information i.e. operative reports, chart notes and because the health plan is requiring information from the patient which has not received a response. Many times a medical biller is the connection between the health insurance company and the patient. The medical biller in order to secure the physician’s reimbursement is often the person who contacts the patient to request a follow-up call with their health insurance. Some billers could be responsible for completing disability forms, obtaining prior authorizations for visits or surgical procedures as well as any number of obstacles standing in the way of clearing the account balance.

The lack of insurance payment is not always due to lack of cooperation from the patient. Many times the insurance carrier is the cause of the delay of the claim payments. Either the carrier did not receive the claim or it was processed incorrectly and the representative will send it again for consideration! Sometimes a claim will go into medical review on a given date but never seems to find its way to the processing for payment department. And a medical biller’s favorite is when the insurance carrier informs you the determination has been made that the claim does not warrant payment!!!!

As a medical biller, you will become familiar with the appeals process. It is one area medical billers spend endless time writing to insurance companies proving the physician’s billing is proper and requires payment. It is not uncommon to submit a couple of appeals before securing payment. Or losing the appeal and writing off the dollar amount billed.

In the medical billing world, you will learn that unless you obtain payment within the first 30 days, each month that passes signifies you will work harder to get the payment. The longer the delay, the less likely you will be successful in securing the payment due to the physician. Personally, I find this to be a direct challenge and do everything in my power to fight for the payment. If in the end, I am successful, I feel great when I hold the payment in my hand or post the payment to a patient’s account. However, even the best fight does not always produce a payment. If the payment is not received, the next step is to adjust (write off as a loss) the charge from the account which means the doctor did not receive reimbursement for his services. Imagine if you did not receive payment for the work you performed. It creates a negative feeling towards the insurance carriers, especially when there seems to be a pattern to deny claims.

Checking Claim Status

As I mentioned earlier, there is a process called checking claim status. This is not something billers are fond of. Claim status verification occurs when a claim is billed but no insurance payment is received within a reasonable amount of time. The process can be extremely frustrating for billers. A telephone call is made to a carrier like Blue Cross. Once you dial the
“Provider services” telephone number, not to be confused with the” member services” telephone number. The conversation goes something like this….Hi, This is Tammy calling from Tammy’s Health Organization regarding claim status. The Blue Cross representative asks a series of questions before you are allowed to ask anything.

This is a typical representation of what is asked:

What is the tax identification number for the provider you are calling about?
What is the provider’s name?
What is the telephone number of the physician’s office?
Are you a participating provider?
What is the member’s identification number you are calling about today?
What is the patient’s date of birth?
Does the patient have any other insurance on file?
What is the date of service of the claim you are calling about?
What is the billed amount of the claim you are calling about?
Have you ever called on this claim before?
When was the claim submitted?

If you are lucky, you will have called the correct Blue Cross location for your inquiry.

If not, after all of the above, you will be told you have not called the correct location; you will be transferred to the correct location but will repeat the same series of questions. Other times, you start dialing your main Blue Cross contact numbers until you locate the correct place.

Once you relay the answers to the questions you are generally advised: “there is no such claim on file, please rebill the claim”. Or you could be advised that the insurance would like more information i.e. office notes for the service, maybe a report, or maybe the father is the primary insurance due to the ‘birthday rule‘. Please bill the correct primary insurance. Meanwhile, you still have no payment and at least 30 minutes has passed since initiating the call.

The birthday rule is a method used when both parents have insurance coverage for a child. The parent whose birthday is first in the year is the primary insurance provider. If the mom was born in January and the dad was born in May, the mom’s insurance is the primary coverage because mom’s birthday is first. This means the mother’s plan must be billed first. Many times you will need to educate parents or patients of the rules in place and not the parent’s preference as many think.

Remember I mentioned a provider telephone number and a member telephone number? You might wonder why two departments and two numbers are needed for the same company? Here is why. Let’s say a claim was denied for payment and the patient was made the responsible party rather than the insurance carrier. First, the patient will contact the doctor’s office asking why the insurance did not make payment. The biller will contact the provider number and the discussion will go something like this…..this is not covered by the patient’s policy. It is considered preventive and the patient does not have preventive coverage. I have my answer and contact the patient with the details. The patient also contacted the insurance carrier at the member telephone number. Of course, the two answers are completely different plus member services usually will tell the patient the claim was denied because the doctor billed it incorrectly…….

The insurance provider does not want to advise you (the patient) the claim is not a covered service because the last thing the member’s representative wants to hear is how much money a patient pays for the coverage and the bill is not paid….two departments, two telephone numbers, two answers and two sets of notes on the patient’s account.

A Medical Biller Wears Many Hats!

Operations in the billing department are busy, busy, busy! The medical biller wears many hats. The duties change daily with few days being similar. I have always found the billing department to be the most important department because, without the billers, no one would be paid! Doctors could operate but could not obtain reimbursement. Coders also rely on the billing department because until the appointment is scheduled and the proper steps are taken there are no details to code. Medical billers work is never done…..While most employees have one central person to answer to, a medical biller is the contact person for patients, physicians, other departments and health insurance companies to name a few.

A Medical Billers Tools, Books and Manuals

A medical biller is expected to understand how to use the CPT, ICD-10 and HCPC’s manuals. Each health insurance carrier has specific expectations to meeting the guidelines for reimbursement as well. It is not in the health insurances best interest to receive a clean claim. Insurance representatives are not looking for the perfection in your claim but rather the opposite. The carrier is looking for careless mistakes to delay payment.

A medical biller is responsible for reviewing claims before sending for payment to determine that each claim submitted is accurately reporting data. Depending on how your office is set up, you likely will be expected to understand and handle various types of health insurance whether it is managed care, PPO, government, or commercial.

Medical billing of health care data is a universal language shared by many entities around the world! In a medical billing office, professional communication skills are a must. You are the contact person between many avenues related to a medical claim. The more knowledge you are able to secure the better you become at your position. I feel that my love of learning and my passion for medical billing and coding have allowed me to share and educate physicians, co-workers and especially patients.

As part of the medical billing process, whether you are a medical biller, a medical coder or any number of supporting personnel, it is absolutely necessary to always do your very best work every time. Remember, medical billers and coders are the guardians of medical data! An excellent reputation for high standards and ethics goes a very long way.

Medical Billing Is An Exciting Career with Daily Challenges

There is always action occurring other than reviewing claims to submit for payment. It is the backbone of a health organization and no two days seem alike. It remains the only employment field that gets me excited to go to work every day!

I have worked for many years as a medical biller and take pride in the many opportunities to learn something new almost every day. I have found my path with new adventures around every medical department corner. If you like to learn, love a challenge, have an analytical thought process, are not afraid of change and want to make a difference in the world, I encourage you to begin your journey today.