If you read the advertisements in the free newspapers in your city, or if you read the ads that pop up on your email account, or if you are searching for a job on an online service, you have learned that medical billing is a growing field needing trained professionals. This is not just salesmanship. It is true.

Even before the Patient Protection and Affordable Care Act of 2010 (PPACA), the standards and requirements for submitting medical claims were complex. The medical reimbursement system in the United States is a convoluted network of regulations, statutes, contractual obligations, and guidelines promulgated by professional associations, health insurance companies, government agencies, and learned common practice.

Twenty years ago, someone without specialized training could get an entry-level position as a medical biller in a physician’s practice, in a hospital, or at another healthcare institution with little or no experience. While the knowledge required was just as specialized, the system itself, and the enforcement of rules, was more relaxed. Medical billers could learn on the job. Healthcare providers, today, need proof that an applicant is ready for the job, and he or she has appropriate training before the date of hire.

Fiscal concerns in the current healthcare climate have led to attempts by third-party payers to tighten reporting requirements in an effort to reduce fraud and abuse of the medical reimbursement system. By limiting payment for combinations of different codes, refining the definitions of codes, and putting a limit on the frequency of certain charges, commercial insurers and government payers scrutinize healthcare claims more closely than ever before. Under the PPACA, this scrutiny will increase.

What Does a Medical Biller Do?

While medical billers understand the language of medical code, many medical billers do not actively review medical records or assign codes in a large institutional setting. They may do so in a small office environment, but their focus is on clean claim submission and prompt payment. Professional medical billers’ primary role in the business function of a healthcare institution is to submit clean claims to third-party payers in compliance with the contractual obligations each party, the health insurance and the the healthcare provider, has agreed to follow to receive appropriate payment for services rendered to covered beneficiaries. Professional medical billers also follow up on claims after payment is received, or if a justifiable claim is denied.

Medical billers understand every field of the CMS-1500 claim form, which is used for outpatient medical billing, and also of the UB-04, which is used for inpatient billing. Completing an accredited program of study at a community college, private school, or online training course, gives medical billers the background to understand every required bit of data needed to receive payment for medically necessary services.

Professional medical billers, today, start their careers with a foundation of basic knowledge that they then apply in the field. The healthcare industry is always changing, and there is always some new wrinkle in the rules that govern claim submission. The system is uniform in that it uses standardized codes to describe patient encounters, procedures, and conditions, but how these standards are interpreted by different payers is always in flux as codes change annually, and as payer documentation requirements become more focused.

NCDs, LCDs, Medical Policies, and Global Periods

Medicare, which is the federal health insurance program that pays for the services provided to most elderly patients, promulgates a series of coverage determinations. Some of these are at the national level, applying across the U.S. (NCDs), while others are local (LCDs), that only apply to a certain geographical area. The Centers for Medicare and Medicaid Services (CMS) maintains a database of NCDs and LCDs. Any care provided that falls under the jurisdiction of an NCD or an LCD must meet certain medical requirements, reflected in the patient’s medical record, in order to be billed and paid appropriately.

The use of botulinum toxins, or botox, is a covered benefit for patients enrolled in Medicare Part B, and by the various state Medicaid programs, but only for certain conditions. Axillary botox injections for the treatment of excessive sweating that is not treatable by other means is covered by Medicare and Medicaid. Botox injections for cosmetic reasons are not entitled to payment by these programs. This is published in an NCD to be followed by all healthcare providers at the national level. The Medicare program has divided the country into 14 jurisdictions to monitor use on a more local level, and Medicare’s fiscal intermediaries are free to publish LCD guidelines within their geographic area to monitor usage and to prevent unnecessary claims. Medical billers know when services will be reimbursed in their area, and when they will not be covered.

Just as the government publishes its own coverage determinations, commercial healthcare insurers publish medical policies that have the same effect. These policies establish baselines of care, and they render judgement on what services are medically necessary for their beneficiaries, under what circumstances, and how these services should be reported in order to the resulting healthcare claims to be paid.

Every time a surgical procedure is performed, all other healthcare services performed after the date of original services fall within a pre-determined global surgical period. Follow-up appointments for evaluation and management of a condition are bundled into the payment of the original surgical procedure. The amount of time can range from ten days to thirty days. If a separately identifiable evaluation and management service is provided that qualifies for reimbursement, professional medical billers can modify a given code to indicate this to a payer, and the forthcoming payment will be received by that provider of medically necessary services.

Experts at Claim Submission

Medical billers are aware of the terms of coverage for a multitude of insurance plans, large and small. They are also able to report claims within the limits and capabilities of both paper and electronic claim submission. Paper claims on CMS-1500 forms and on UB-04s may be required for smaller payers. When a paper CMS-1500 is required, only four diagnosis codes can be reported. The same claim, submitted electronically, can contain eight diagnosis codes. Knowing how to tailor a claim according to the payer, and according to the format used to submit a claim, professional medical billers decrease the percentage of rejected claims on technical grounds, and speed timely cash flow for a healthcare provider.

Professional medical billers also understand the importance of the correct demographic information being reported on a healthcare claim, in addition to the proper reporting of procedures and conditions. If a third-party payer cannot recognize the patient as their beneficiary, either because policy or identification numbers are transposed, the date of birth is incorrect, or the name a patient provides is different from the name on his or her insurance contract, the claim will be returned to the healthcare provider as being non-covered. With attention to detail, medical billers correct demographic information, bill the primary payer, and, when applicable, submit claims to a secondary or tertiary payer depending on what insurance the patient carries.

Medical Billers are Specialized Bookkeepers

While submitting clean claims is the most important thing a medical biller can do to ensure appropriate and timely cash flow, they also post payments to individual accounts. Based on the fee schedule each healthcare provider agrees to when they sign a contract to see an insurer’s patients, medical billers write off excess monetary charges that are in excess of the fee schedule so that the patient is billed the amount dictated by their insurance contract. Medical billers do not only bill insurers, but they also bill patients for deductibles, co-insurance, and for copays that were not collected at the time of service. They also appeal claims that have been improperly denied payment so that the patient receives the benefits they are due.

Unlike certified medical coders, professional medical billers are trained in the practice of claims submission and follow-up, rather than in the theory of medical code. They are a valuable resource for healthcare institutions because they ensure that healthcare claims are submitted appropriately, and that the financial reimbursement is received according to the legal standards that govern the profession.