Archive for February, 2011

Medical Billing Glossary

February 28, 2011

Account Number – Number you’re given by your doctor or hospital for a medical visit.

Actual Charge – The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount an insurance plan approves.

Adjustment – The portion of your bill that your doctor or hospital has agreed not to charge you.

Admission Date (Admit Date) – Date you were admitted for treatment.

Admission Hour – Hour when you were admitted for inpatient or outpatient care.

Admitting Diagnosis – Words that your doctor uses to describe your condition

Advance Beneficiary Notice (ABN) – A notice the hospital or doctor gives you before you’re treated, telling you that Medicare will not pay for some treatment or services. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.

Advance Directive (Healthcare) – Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.

All-inclusive Rate – Payment covering all services during your hospital stay.

Ambulatory Payment Classifications (APC) – A Medicare payment system that classifies outpatient services so Medicare can pay all hospitals the same amount.

Ambulatory Care – All types of health services that do not require an overnight hospital stay.

Ambulatory Surgery – Outpatient surgery or surgery that does not require an overnight hospital stay.

Amount Charged – How much your doctor or hospital bills you.

Amount Paid – The dollar amount that you paid for your doctor or hospital visit.

Amount Not Covered – What your insurance company does not pay. It includes deductibles, co-insurances, and charges for non-covered services.

Amount Payable by Plan – How much your insurer pays for your treatment, minus any deductibles, co-insurance, or charges for non-covered services.

Ancillary Service – Services you need beyond room and board charges, such as laboratory tests, therapy, surgery and the like.

Anesthesia – Drugs given to you during surgery to eliminate or reduce surgical procedure pain. 

Appeal – A process by which you, your doctor, or your hospital can object to your health plan when you disagree with the health plan’s decision to not pay for your care.

Applied to Deductible – Portion of your bill, as defined by your insurance company, that you owe your doctor or hospital.

Assignment – An agreement you sign that allows your insurance to pay the doctor or hospital directly.

Assignment of Benefits – When insurance payments are sent directly to your doctor or hospital.

Attending Physician Name – The doctor who certifies that you need treatment and is responsible for your care.

Authorization Number – A number stating that your treatment has been approved by your insurance plan. Also called a Certification Number or Prior-Authorization Number.

Balance Bill – How much doctors and hospitals charge you after your health plan, insurance company, or Medicare have paid its approved amount.

Beneficiary – Person covered by health insurance.

Beneficiary Eligibility Verification – A way for doctors and hospitals to get information about whether you have insurance coverage.

Beneficiary Liability – A statement that you are responsible for some treatments or charges.

Benefit – The amount your insurance company pays for medical services.

Bill/Invoice/Statement – Printed summary of your medical bill.

Cardiology Charges – Charges for heart procedures. Examples are heart catheterization and stress testing.

Case Management – A way to help you get the care you need, especially when you need pre-authorized care from several services. Usually a nurse helps arrange for your care.

Centers for Medicare and Medicaid (CMS) – The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

CHAMPUS – Insurance linked to military service, also known as TriCare.

Charity Care – Free or reduced-fee care for patients who have financial hardship.

Claim – Your medical bill that is sent to an insurance company for processing.

Claim Number – A number given to a medical service.

Claims Review – The method by which a patient’s health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.

Clean Claim – A claim that does not have to be investigated by insurance companies before they process it.

Clinic – An area in a hospital or separate building that treats regularly scheduled or walk-in patients for non-emergency care.

COBRA Insurance – Health insurance that you can buy when you lose your job. It is generally more expensive than insurance provided through your job but less expensive than insurance purchased on your own when you are unemployed.

Coding of Claims – Translating diagnoses and procedures in your medical record into numbers
that computers can understand.

Co-insurance – The cost sharing part of your bill that you have to pay.

Co-insurance Days (Medicare) – Hospital Inpatient Medicare coverage from day 61 to-day 90 of continuous hospitalization. You are responsible for paying for part of those days. After the 90th day, you enter your “Lifetime Reserve Days”.

Collection Agency – A business that collects money for unpaid bills.

Consent (for treatment) – An agreement you sign that gives your permission to receive medical services or treatment from doctors or hospitals.

Contractual Adjustment – A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.

Coordination of Benefits (COB) – A way to decide which insurance company is responsible for payment if you have more than one insurance plan.

Co-pay – Agreed amount of the charges for medical services that patients or guarantors must pay.

Coronary Care – Routine charges for care you receive in a heart center because you need more care than you can get in a regular medical unit.

Covered Benefit – A health service or item that is included in your health plan, and that is paid for either partially or fully.

Covered Days – Days that your insurance company pays for in full or in part.

CPT Codes – A coding system used to describe what treatment or services were given to you by your doctor.

CT Scan – A type of X-ray of the head or body; usually done in a hospital’s x-ray department.

Date of Bill – The date the bill for your services is prepared. It is not the same as the date of service.

Date of Service (DOS) – The date(s) when you were treated.

Days – The total number of days that you are being charged for the hospital’s services.

Deductible – How much cost sharing that you must pay for medical services often before your insurance company starts to pay.

Description of Services – Tells what your doctor or hospital did for you.

Diagnosis Code (ICD9 Code) – A code used for billing that describes your illness.

Diagnosis – Related Groups (DRGs) – A payment system for hospital bills. This system categorizes illnesses and medical procedures into groups for which hospitals are paid a fixed amount for each admission.

Discharge Hour – Hour when you were discharged.

Discount – Dollar amount taken off your bill, usually because of a contract with your hospital or doctor and your insurance company.

Drugs/Self Administered – Drugs that do not require doctors or nurses to help you when you take them. You may be charged for these. You will need to check with your doctor or hospital regarding their policy on this.

Due from Insurance – How much money is due from your insurance company.

Due from Patient – How much you owe your doctor or hospital.

Durable Medical Equipment (DME) – Medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.

EEG – Equipment or medical procedure that measures electricity in the brain.

EKG/ECG – Equipment or medical procedure that measures how your heart works, and your doctor’s reading of the results.

Eligible Payment Amount – Those medical services that an insurance company pays for.

Emergency Care – Care given for a medical emergency when you believe that your health is in serious danger when every second counts.

Emergency Room – A special part of a hospital that treats patients with emergency or urgent medical problems.

Estimated Insurance – Estimated cost paid by your insurance company.

Enrollee – A person who is covered by health insurance.

Estimated Amount Due – How much the doctor or hospital estimates you or your insurance company owes.

Exclusion – Services or supplies not covered under a health plan.

Explanation of Benefits (EOB/EOMB) – The notice you receive from your insurance company after getting medical services from a doctor or hospital. It tells you what was billed, the payment amount approved by your insurance, the amount paid, and what you have to pay.

External Cause of Injury Code – A code describing a place or item that may have caused injuries, poisoning, or health problems.

Federal Tax ID Number – A number assigned by the federal government to doctors and hospitals for tax purposes.

Fee Schedule  – A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.

Financial Responsibility – How much of your bill you have to pay.

Fiscal Intermediary (FI) – A Medicare agent that processes Medicare claims.

Fraud and Abuse – Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by the insurance plan. This is not the same as fraud.

Guarantor – Someone who has agreed to pay the bill.

HCFA 1500 Billing Form – A form used by doctors to file insurance claims for medical services.

HCPCS Codes – A coding system used to describe what treatment or services were given to you by your doctor.

Health Care Financing Administration (HCFA) – Former name of the government agency now called the Centers for Medicare & Medicaid Services.

Healthcare Provider – Someone who provides medical services, such as doctors, hospitals, or laboratories. This term should not be confused with insurance companies that “provide” insurance.

Health Insurance – Coverage that pays benefits for sickness or injury. It includes insurance for accidents, medical expenses, disabilities, or accidental death and dismemberment.

Health Maintenance Organization (HMO) – An insurance plan that pays for preventive and other medical services provided by a specific group of participating providers.

HIPAA – Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information.

Home Health Agency – An agency that treats patients in their homes.

Hospice – Group that offers inpatient, outpatient, and home healthcare for terminally ill patients.

Hospital Inpatient Prospective Payment System (PPS) – A federal system that pays a fixed fee for inpatient care.

In-of-Network Provider – A doctor or other healthcare provider who is contracted as part of an insurance plan’s doctor or hospital network. Same as participating provider.

Incremental Nursing Charge – Charges for nursing services added to basic room and board charges.

Inpatient (IP) – Patients who stay overnight in the hospital.

Insurance Cap – An insurance cap is the total lifetime dollar amount that a provider will pay on a particular policy. Many insurance companies have a lifetime cap of $1 million, which can be easily attained in cases of prolonged medical treatment and care.

Insurance Company Name – Name of the company that your claim will be sent to.

Insured Group Name – Name of the group or insurance plan that insures you, usually an employer.

Insured Group Number – A number that your insurance company uses to identify the group under which you are insured.

Insured’s Name (Beneficiary) – The name of the insured person.

Intensive Care – Medical or surgical care unit in a hospital that provides care for patients who need more care than a general medical or surgical unit can give.

Internal Control Number (ICN) – A number assigned to your bill by your insurance company or their agent.

International Classification of Diseases, 9th Edition (ICD-9-CM) – A coding system used to describe what treatment or services your doctor gave to you.

IV Therapy – Treatment provided by giving intravenous solutions or drugs.

Labor and Delivery Room – A unit of a hospital where babies are born.

Laboratory – Charges for blood tests and tests on body tissue samples, such as biopsies.

Lifetime Reserve Days (Medicare) – Under Medicare, you have a lifetime reserve of 60 more days of inpatient services after you use the first 90 benefit days. You must pay a fixed amount for each day of service.

Long-Term Care – Care received in a nursing home. Medicare does not pay for long-term care unless you need skilled nursing or special rehabilitation.

Mailer/Summary of Account – A monthly summary of services (and charges?) mailed to the person who pays the bill.

Managed Care – An insurance plan that requires patients to see doctors and hospitals that have a contract with the managed care company, except in the case of medical emergencies or urgently needed care if you are out of the plan’s service area.

Medicaid – A state administered, federal and state funded insurance plan for low-income people who have limited or no insurance.

Medical Record Number – The number assigned by your doctor or hospital that identifies your individual medical record.

Medical/Surgical Supplies – Special supplies, such as materials used to repair a wound or instruments used for your care.

Medicare – A health insurance program for people age 65 and older. Medicare covers some people under age 65 who have disabilities or end-stage renal disease (ESRD).

Medicare + Choice – A Medicare HMO insurance plan that pays for preventive and other healthcare from designated doctors and hospitals.

Medicare Approved – Medical services for which Medicare normally pays.

Medicare Assignment – Doctors and hospitals who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.

Medicare Number – Every person covered under Medicare is assigned a number and issued a card for identification to providers.

Medicare Paid – The amount of your bill that Medicare paid.

Medicare Paid Provider – The amount of your bill that Medicare paid to your doctor or hospital.

Medicare Part A – Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.

Medicare Part B – Helps pay for doctor services, outpatient care, and other medical services not paid for by Medicare Part A.

Medicare Summary Notice (MSN) – The notice you receive from Medicare after getting services from your doctor or hospital. It tells you what was billed to Medicare, Medicare’s approved payment, the amount Medicare paid, and what you have to pay. Also called an Explanation of Medicare Benefits (EOMB).

Medigap – Medicare Supplement Insurance that pays for some services not covered by Medicare A or B, including deductible and co-insurance amounts.

MRI – A type of X-ray; magnetic resonance brain or body images, usually done in a hospital’s x-ray department.

Network – A group of doctors, hospitals, pharmacies, and other health care experts hired by a health plan to take care of its members.

Non-Covered Charges – Charges for medical services denied or excluded by your insurance. You may be billed for these charges.

Non-Participating Provider – A doctor, hospital, or other healthcare provider that is not part of an insurance plan’s doctor or hospital network.

Nursery – Nursing care charges for newborn babies.

Observation – Type of service used by doctors and hospitals to decide whether you need inpatient hospital care or whether you can recover at home or in an outpatient area. Usually charged by the hour.

Oncology – Charges for treating cancer and related diseases.

Operating Room – A hospital or clinic area where surgeries are done.

Other Room and Board – Any extra charges that cannot be included in routine room and board charges.

Out-of-Network Provider – A doctor or other healthcare provider who is not part of an insurance plan’s doctor or hospital network. Same as non-participating provider.

Out-of-Pocket Costs – Costs you must pay because Medicare or other insurance does not cover them.

Outpatient (OP) – Patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, x-rays, and some surgeries.

Outpatient Service – A service you receive in one day at a hospital or clinic without staying overnight.

Over-the-Counter Drug – Drugs not needing a prescription that you buy at a pharmacy or drug store.

Paid to Provider – Amount the insurance company pays your medical provider.

Paid to You – Amount the insurance company pays you or your guarantor.

Participating Provider – A doctor or hospital that agrees to accept your insurance payment for covered services as payment in full, minus your deductibles, co-pays and co-insurance amounts.

Patient Amount Due – The amount charged by your doctor or hospital that you have to pay.

Patient Type – A way to classify patients–outpatient, inpatient, etc.

Pay This Amount – How much of your bill you have to pay.

Per Diem – Charged/Paid by the day.

Pharmacy Charges – Cost of drugs given under a pharmacist’s direction.

Physical Therapy – Treatment of diseases or injuries by exercise, heat, light, and/or massage.

Physician – Person licensed to practice medicine.

Physician Extenders – Also called mid-level service providers. Physician extenders include licensed nurse practitioners and/or licensed physician assistants. They coordinate patient care under a doctor’s supervision.

Physician Office – Your doctor’s office.

Physician Practice – A group of doctors, nurses, and physician assistants who work together.

Physician Practice Management – Non-physician staff hired to manage the business aspects of a physician practice. These staff include billing staff, medical records staff, receptionists, lab and X-ray technicians, human resources staff, and accounting staff.

Point-of-Service Plan (POS) – An insurance plan that allows you to choose doctors and hospitals without having to first get a referral from your primary care doctor.

Policy Number – A number that your insurance company gives you to identify your contract.

Pre-Admission Approval or Certification – An agreement by your insurance company to pay for your medical treatment. Doctors and hospitals ask your insurance company for this approval before providing your medical treatment.

Pre-Existing Condition – A health condition or medical problem that you already have before you sign up to receive insurance. Some health insurers may not pay for health conditions you already have.

Pre-payments – Money you pay before getting medical care; also referred to as pre-admission deposits.

Prevailing Charge – A billing charge that is commonly made by doctors in a specific region or community. Your insurance company determines this charge.

Primary Care Network (PCN) – A group of doctors serving as primary care doctors.

Primary Care Physician (PCP) – A doctor whose practice is devoted to internal medicine, family/general practice, or pediatrics. Some insurance companies consider Obstetrician/gynecologists primary care physicians.

Primary Insurance Company – The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.

Private Room (Deluxe) – A more expensive hospital room than those available to other patients. You may have to pay extra for this type of room if it is not a medical necessity.

Procedure Code (CPT Code) – A code given to medical and surgical procedures and treatments.

Prospective Payment System (PPS) – A Medicare system that pays hospitals a set amount for covered diagnostic or treatment services.

Provider – A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.

Provider Contract Discount – A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.

Provider Name, Address, and Phone # – Name and address of the doctor or hospital submitting your bill.

Psychiatric/Psychological Treatments – Nursing care and other services for emotionally disturbed patients, including patients admitted for inpatient care and those admitted for outpatient treatment.

Radiology – X-rays used to identify and diagnose medical problems.

Reasonable and Customary (R & C) – Billing charges that insurers believe are appropriate for services throughout a region or community. 

Recovery Room – A special room where you are taken after surgery to recover before being sent home or to your hospital room.

Referral – Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans usually require referrals from your primary care doctor to see specialists or for special procedures.

Referring Physician – A physician who sends a patient to another doctor for specialty care or services.

Release of Information – A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims.

Renal Dialysis – Removal of wastes from the blood. Normally the kidneys would remove these wastes if they were functioning properly.

Respiratory Therapy – Giving oxygen and drugs through breathing, as well as other therapies that measure inhaled and exhaled gases and blood samples.

Responsible Party – The person(s) responsible for paying your hospital bill–usually referred to as the guarantor.

Revenue Code – A billing code used to name a specific room, service (X-ray, laboratory), or billing sum.

Room and Board Private – Routine charges for a room with one bed.

Room and Board Semi-Private – Routine charges for a room with two beds.

Same-Day Surgery – Outpatient surgery.

Secondary Insurance – Extra insurance that may pay some charges not paid by your primary insurance company. Whether payment is made depends on your insurance benefits, your coverage, and your benefit coordination.

Service Area – Geographic area where your insurance plan enrolls members. In an HMO, it is also the area served by your doctor network and hospitals.

Service Begin Date – The date your medical services or treatment began.

Service Code – A code describing medical services you received.

Service End Date – The date your medical services or treatment ended.

Skilled Nursing Facility – An inpatient facility in which patients who do not need acute care are given nursing care or other therapy.

Source of Admission – The source of your admission—referral, transfer, emergency room, etc.

Specialist – A doctor who specializes in treating certain parts of the body or specific medical conditions. For example, cardiologists only treat patients with heart problems.

Statement Covers Period – The date your services or treatment begin and end.

Submitter ID – Identification number (ID) that identifies doctors and hospitals who bill by computers. Doctors and hospitals get an ID from each insurance company to whom they send claims using the computer.

Subscriber – A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.

Supplemental Insurance Company – An additional insurance policy that handles claims for deductible and co-insurance reimbursement.

Swing Bed – Bed for a patient who receives skilled nursing care in a non-skilled nursing facility. 

Total Charges – Total cost of your medical services.

Type of Admission – The reason for your admission, such as emergency, urgent, elective, etc.

Type of Bill – A bill that shows what type of care is being billed, such as hospital inpatient, hospital outpatient, skilled nursing care, etc.

UB92 Billing Form – A form used by hospitals to file insurance claims for medical services.

Units of Service – Measures of medical services, such as the number of hospital days, miles, pints of blood, kidney dialysis treatments, etc.

Utilization Review (UR) – Hospital staff who work with doctors to determine whether you can get care at a lower cost or as an outpatient.

You May be Billed – A phrase used by your insurance company informing you that your doctor or hospital may bill some charges directly to you.



February 24, 2011

“The majority of men meet with failure because of their lack of persistence in creating new plans to take the place of those which fail.”  -Napoleon Hill

The Medical Billing Industry

February 21, 2011

I get asked frequently:  How did you get into Medical Billing?  Can I get started without any experience?  Is it true you can make lots of money at this?  Do you think it is something I can do?  Is it true you can do this from home?  If these are questions you have had, I hope this article will help answer them for you.

As of the date of this article, I have 15 years experience in the Medical Billing industry and I answer the question about how I got into the field here.  You can get started without experience, just as I did, but without experience you will have a hard time convincing a physician or practice manager that you know what you are talking about and that they should entrust you with such a substantial part of an impact to their practice, remember you are dealing with the cash-flow of their business.  A physician is going to want to see that you have a history of experience, knowledge pertinent to their specialty and an ability to collect on their claims.  I would recommend anyone wanting to get into the Medical Billing industry obtain a position working in the medical field directly with someone who has this knowledge and begin learning the industry in a hands on method.  This process is critical for success as to learn all this on your own without anyone that has the expertise needed would make a challenging career even more challenging, and a lot of mistakes would be made by trial and error that can be avoided!  

The health insurance industry and medical billing industry go hand-in-hand and are ever-changing. Federal and State regulations are continuously changing and unless you are prepared to continue education and stay up on the rules you will only be frustrated by the results of your efforts.  This is not a field you learn the basics and don’t have to continue to learn the industry.  Education and knowledge are one of the main keys, if you are willing to invest the time in learning the industry, understand that there are very strict regulations, have a growing commitment to continued education, have an aptitude for attention to detail, comprehend the requirements and need for accuracy, know you will need to fight to get things resolved and not sit back and wait for the process to happen, then you will be an excellent Medical Biller and you can be very successful. In order to be successful in an overwhelmed industry with a greater need then was there say 10 years ago for medical billing, you have to educate providers on all the benefits of outsourcing on top of marketing your education and/or experience.  The term medical billing is very generic because the title doesn’t convey all that is involved.  To be an excellent Medical Biller you will have to have strong knowledge of financial concepts and accounting principles, be well-organized, detail oriented, efficient, accurate, strong analytical skills, ability to multi-task, willing to fight for your rights, understand all rules and regulations (including but not limited to federal, state, provider, insurance carrier, etc), understand the importance of follow-up and promptness, ability to explain to both the physician and the patient every aspect regarding their benefits and the way a claim was processed, etc.  The process of medical billing involves everything from benefit verification to claims follow-up, appeals, payment posting, recoupments, refunds, overpayments, patient billing, providing your client with precise and accurate statistical reports on the health of their practice, etc.  Basically you are following every claim from beginning to end to create a zero balance, this sounds easier said than done. Let’s look at the various elements of what you need to provide your client with these services:

  • Understand the CPT, HCPCS, and ICD9 Rules and Regulations
  • Understand and identify Modifiers and their various uses
  • Understand the importance of verifying and understanding patient’s benefits
  • Understand the importance of obtaining and understanding managed care authorizations and coverage limitations
  • Understand the various types of insurance plans available and being able to differentiate each plan and how they are constructed (HMO, PPO, Indemnity, POS, Workers Compensation)
  • Understand the insurance contracts for you provider
  • Understanding government payers as well as federal and state regulations
  • Understanding the CMS HCFA1500 form and UB92 form
  • Understand each element of the electronic claims filing process
  • Understanding the HIPAA Regulations (Health Insurance Portability and Accountability Act) and adhering to the rules
  • Understanding the importance of compliance as well as policies and procedures
  • Understand the importance of continued education, both on-line or in-class (seminars, association memberships, insurance bulletins, etc)

Many advertisers market Medical Billing as someone who just files insurance claims and makes a lot of money doing so from home.  Yes, you can do medical billing from home, but it isn’t something you just push a button and it happens, it does take a skilled person to be involved in the process, it is not 100% automated.  Can money be made at Medical Billing?  Yes.  Is it lucrative?  No.  Just like any other industry out there, greater money is made by hard work and effort, it is not a get rich quick scheme.  If you want to make good money, you are going to have to work very hard to do so.  It is a rewarding industry if you put the time and effort into learning it.


February 17, 2011

“The leader who exercises power with honor will work from the inside out, starting with himself.”  -Blaine Lee

Texas Workforce Commission Winter 2011 Publication

February 15, 2011

Have you read the Texas Workforce Commission Winter 2011 publication?  It is now available online.  Click the link here to read or save your copy:

Medical Billing vs Medical Coding

February 14, 2011

Medical Billing is the practice of submitting reimbursement claims to Insurance companies (e.g. Blue Cross Blue Shield) or the United States government (e.g. Medicare or Medicaid), in order to receive payment for services provided to a patient by a doctor.

Medical Coding is the practice of putting the procedure codes (CPT or HCPCS Code) and diagnosis codes (ICD9 Codes) in a format to be paid by the insurance company.   This information is provided by the office visit notes and then reviewed for entering and transmission.

The terms Medical Coding and Medical Billing are often used synonymously, however, medical coding must be performed by a medical coder before the medical billing reimbursement claim can be submitted.  Medical Billing is a subspecialty of Medical Coding.

Medical Billing in the physician office is typically performed by a clerk through medical billing software. After a physician sees and diagnoses the patient, and performs the necessary procedure, the physician then makes his/her notes of the diagnosis and procedure and gives those notes to the Medical Coder. The physician’s diagnosis and procedure is then properly coded before the medical billing reimbursement claim can be submitted. After the medical coding is completed, the medical billing claim can be completed and submitted for reimbursement.

Although there are programs that offer Medical Billing training by itself, if you are going to consider a course, you should consider a program that combines both billing and coding in one training program, since Medical Coding is the first step in the medical billing process.


February 10, 2011

“The first responsibility of a leader is to define reality. The last is to say thank you. In between, the leader is a servant.”  -Max de Pree

What exactly is Medical Billing?

February 7, 2011

I have been in the Medical Billing industry for 15 years and I get asked this question frequently by people I network with and by my friends in curiosity:  Just what exactly is Medical Billing?  This article will give you a general understanding of what it is and how the processes is done.  

Medical Billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. Basically the medical billing process is an interaction between the health care provider and the insurance company (aka the payer).

Prior to actually performing medical services to the patient and/or billing services to an insurance company, the health care provider checks the eligibility & benefits of the patient for the intended services with the patient’s insurance company.  This process is called an Eligibility & Benefits Inquiry.  The information obtained discloses to the provider of service the benefits the patient has in regards to the co-payment, deductible, co-insurance, out-of-pocket expense, exclusions & limitations, along with pre-existing information.  These benefits should be explained to the patient before services are rendered in case the patient has any questions and to avoid issues later.  The provider will render medical services to the patient and the findings will be reported in the patient record which contains highly personal information, including the nature of the illness, examination details, medication lists, diagnoses, and suggested treatment.  The extent of the physical examination, the complexity of the medical decision-making and the background information (history) obtained from the patient are evaluated to determine the correct level of service that will be used to bill the insurance. The level of service, once determined by the qualified staff is then translated into a standardized five digit procedure code drawn from the CPT (Current Procedural Terminology) database. The diagnosis is translated into a numerical code as well, drawn from a similar standardized ICD-9 (soon to be ICD-10) database.  Once the procedure and diagnosis codes are determined, the medical biller will transmit the data electronically (or via paper if specified by the payer) on a claim form (either a HCFA1500 or UB92; both known as a claim forms – one for out-patient providers and one for in-patient providers) showing the patient’s demographic information, insurance policy, provider of service, CPT code, ICD-9 code, fees for services rendered, payment made at the time of service, along with other data required for transmission and processing for payment.  The insurance company (payer) then processes the claim(s) according to several factors.  This process is done by medical claims examiners or medical claims adjusters, and the claims are evaluated for their validity for payment using rubrics (a type of procedure) for patient eligibility, provider credentials, clean claim requirements, and medical necessity.  If the provider is an In-Network provider, the approved claims are reimbursed at the negotiated contract rate.  If the provider is an Out-of-Network provider, the claims are processed according to the patient’s benefits.  Rejected and failed electronic claim notices are sent to provider for review.  The information is then deciphered, reconciled, required corrections are made (if applicable) and the claim is resubmitted to the payer (if applicable).  Once the provider receives the EOB (Explanation of Benefits), RA (Remittance Advice) or R&S (Remittance and Status), the claim is then processed and the data reconciled and the patient will be balance billed for any additional amount due.  However, if the claim was paid incorrectly by the payer or denied by an insurance company inaccurately, it must be appealed.  The goal of the provider is to have limited rejections, denials, and errors made on behalf of either party (the provider and/or payer).   This exchange of claims and rejections may be repeated multiple times until a claim is paid in full, the balance is applied to the patient’s responsibility, or the provider relents and accepts an incomplete reimbursement due to contract guidelines or exhaustion of appeal rights.   The medical billing process can take anywhere from several days to several months to complete, and require several iterations before a resolution is reached. 

This medical billing process outlined here is generally the same for most insurance companies, whether they are private companies or government-owned, however there are policy guidelines and regulations that govern the benefits, change the way claims are paid and processes are done.  The health care provider or medical biller must have complete knowledge of different insurance plans, federal laws, state laws, and insurance regulations that preside over them in order to be able to process the claim and receive maximum reimbursement.   When providers agree to accept an insurance company’s plan, the contractual agreement includes many details including fee schedules which dictate what the insurance company will pay the provider for covered procedures and other rules such as timely filing guidelines and prompt pay requirements.  

Medical billers are encouraged, but not required by law to become certified. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field, but they do not teach you the concepts to actually be a medical biller or provide a medical billing service. 

In many cases, particularly as a practice grows beyond its initial capacity to cope with its own paperwork, providers outsource their medical billing process to a third-party known as a Medical Billing Service. These entities reduce the burden of paperwork for medical staff and recoup lost efficiencies caused by workload saturation, lack of experience at claim resolution and insurance guidelines, reduction in payroll expenses of the practice (typically the Medical Billing Service is paid a percentage of collections not just earning an hourly wage regardless of physician’s reimbursement), along with an overall greater efficiency hence paving the way for further practice growth.

Tax Time Check List

February 4, 2011

None of us just love tax time…in all seriousness, I don’t even think CPA’s do!  We have created a list for you to assist you in what you need to have together to file your 2010 Tax Return. 

Here is a Tax Return Checklist:

  • W2 & 1099’s – Wages and Compensation
  • Proof of jury duty pay
  • 1099-INT and/or 1099-DIV Interest and Dividends received
  • 1099-R Pensions, Annuities and other Retirement Accounts
  • IRA contributions (traditional, SEP, or rollovers)
  • 1099-B form(s) showing Brokerage Trades in Stocks and Bonds
  • 1099-G Unemployment Compensation and State Refunds from 2009
  • 1099-SSA form showing Social Security received
  • Schedule C /1099-MISC Reporting income and expenses for a small business/self employed income
  • Mileage Log
  • K-1 forms for income from a partnership, small business, or trust
  • Schedule D Capital Gains and Losses
  • Form 982 Used to report a cancellation of debt on a 1099-C
  • Record of income and expenses for your Rental Property
  • HUD-1 Escrow statement for property you bought or sold
  • Alimony received
  • Gifts to Charity/Donation Receipts
  • Healthcare Expenses (doctors, dentists, health insurance, eyecare, medicine)
  • Summary of Moving Expenses
  • Summary of Educational Expenses/College Tuition
  • 1098-E Student Loan interest paid
  • Summary of Child Care, Day Care, or Adult Day Care Expenses
  • Real Estate/Property Taxes
  • Motor Vehicle Registration
  • 1098 Mortgage interest paid
  • Job-related Expenses (union dues, job education, uniforms)
  • Loss of property due to casualty or theft
  • Gambling losses
  • Last year’s tax preparation fees

Be sure to bring written documents for additional income not reported on a W-2 or 1099 form, such as other self-employment income, rental income, or alimony. This could be a spreadsheet, bank statements, or other written evidence. Bring canceled checks, receipts, or spreadsheets for any tax-related expenses. This may include contributions to your traditional or SEP-IRA, moving expenses, college expenses, medical and dental expenses, real estate taxes, gifts to charities and churches, and daycare or childcare costs.  If you paid estimated taxes, bring a summary of your federal and state estimated payments and canceled checks.


February 3, 2011

“Reason and judgment are the qualities of a leader.”  -Tacitus