Not all healthcare heroes wear scrubs. Some work behind the scenes to ensure that medical providers are reimbursed for their services and that patients are billed accurately for the care they receive. Medical insurance billing and coding may not be a glamorous job, but it’s an integral part of medicine and a rewarding career with extraordinary possibilities.
What Does a Medical Insurance Billing and Coding Specialist Do?
Medical insurance billing and coding specialists manage insurance claims and other financial tasks in healthcare offices. As allied health professionals, they play a key role in the healthcare revenue cycle, the complex process by which doctors, and medical facilities are paid.
Responsibilities include:
Medical Coding
Medical coding is a type of shorthand, a system of short, alphanumeric codes that describe:
- Symptoms
- Diagnoses
- Treatments
- Surgical procedures
- Diagnostic tests
- Causes of death
- Medical equipment
- Non-medical but related services, such as ambulance transportation
Codes condense volumes of information into a page or two of data for each patient encounter, making data sharing more efficient and manageable. As a medical insurance billing and coding specialist, you’ll research charts and code insurance forms for billing.
Filing Insurance Claims
The US generates trillions of dollars in medical bills annually, most are covered by health insurers. Medical insurance billing and coding specialists prepare paper and electronic claim forms, working with insurers to ensure prompt reimbursement.
Troubleshooting Rejected Claims
Some first-time health insurance claims are rejected. The most commons reasons include:
- Coding errors
- Questions about the medical necessity of treatments
- Cost control, policies that require trying less costly alternative treatments first
- Because of lack of pre-authorization or notification, some services must be approved in advance.
Medical billing and coding specialist review rejected claims, fix the errors, and resubmit the forms, filing appeals when necessary.
Recordkeeping
Medical billing specialists collaborate with providers to ensure that health records are accurate and complete, chasing down missing documents while requesting necessary updates and corrections.
Tracking Payments
Medical bills are typically shared by the patient and one or more insurers. Each pays their share in the order of liability. Negotiated rates, early payment discounts and other adjustments, such as interest on overdue payments, complicate the process further. Billing and coding specialists track the payments on each balance, keeping a running tally.
Managing Regulatory Compliance
Medical billing is subject to a wide range of rules, violations of which may result in significant financial penalties. Medical billing specialists work closely with patients, clinicians and healthcare providers to maintain strict legal and ethical standards.
Benchmarking and Financial Reporting
Coding creates a searchable database of health information that facilities and public health agencies use to:
- Track encounters
- Surveil disease rates
- Review treatment utilization
- Explore outcomes
- Understand costs
Medical billing and coding specialists participate in quality improvement initiatives by creating performance reports.
Client Care
Medical billing specialists guide patients through what can be a complicated and frustrating billing process by:
- Explaining the claims process
- Requesting insurance pre-authorizations on the patient’s behalf
- Answering general questions about balances owed
- Investigating billing errors
- Helping clients find funding resources, including government insurance, free care programs and credit options
How Do I Become a Medical Insurance Billing and Coding Specialist?
Colleges offer billing and coding programs, but why spend years in school when you can launch your career in months with a vocational school diploma? Full-time students graduate work-ready and qualified for many of the same positions as their peers with degrees.
The curriculum is comprehensive but career-focused, saving you precious time by eliminating general elective courses that won’t make you a better billing and coding specialist. You’ll get to work on what counts while enjoying perks, including lifestyle-friendly schedules, financial aid options, and job placement services upon graduation.
What Can I Do with a Medical Insurance Billing and Coding Diploma?
The best part about a medical billing and coding career is its potential. If you fear being trapped in one work setting with a singular focus, don’t be. With a vocational school diploma, you have options. You can work for:
Hospitals
There are dozens of roles for billing and coding specialists in hospitals, such as:
Claims Specialist – processes insurance claims. You’ll research patients’ health data, code insurance forms, and submit claims. In this position, you’ll work with a team of peers, reaching out to insurers and providers only as needed. Contact with patients is limited, so it’s a great job if you prefer a quiet and consistent routine.
Patient Account Representative – handle individual accounts, ensuring that patients are billed accurately. Primary responsibilities include processing insurance payments, reconciling accounts, and invoicing patients for the balance.
But it’s also a customer-facing position in which you’ll interact with patients to answer billing questions, resolve disputes, and provide information about payment options. Patient account representatives also participate in collection efforts, including sending reminder notices, making phone calls, setting up payment plans, and forwarding long-overdue balances to collection agencies.
Accounts Receivable Specialist – focus on payments owed to the facility. The duties are similar to a claims specialist’s but with an emphasis on problem claim follow-up. You’ll work with providers on challenging appeals, digging into denials, and negotiating with insurers for payment. If you have an aptitude for research and investigation, it’s a gratifying role.
Medical Records Specialists – also known as health information technicians, they manage health and financial records. They also organize, maintain and update files, ensuring that they’re accurate, complete, accessible, and secure.
Responsibilities include responding to record requests from patients, providers, insurers, and billing departments. You may also analyze health data to identify trends that inform clinical and financial decision-making. Researching, for example, how many patients pay their bills early when offered a discount helps administrators set payment policies.
Private Practices
Private practices hire medical billing specialists to manage the claims process. You’ll be part of a small team in which members handle fewer transactions but have a broader range of responsibilities, acting as a claims specialist, patient representative and medical records specialist.
The duties are similar, but the atmosphere is less strenuous. You’ll work with providers, insurers, patients, and affiliated facilities to ensure timely reimbursement. Other responsibilities may include requesting insurance pre-authorizations, accepting cash payments, making bank deposits, and general financial duties.
Insurance Companies
Medical billing and coding specialists work for insurers, reviewing claims and making coverage determinations. You’ll decide, for example, if a claim demonstrates a medical necessity for the services provided, stamping it approved or denied. When claims specialists from the hospital call, you’ll be the voice on the other end of the phone.
You may also issue reimbursements, cutting paper checks or processing electronic claims. And occasionally, you’ll work with clients to iron out disputes. If you’re interested in seeing how the healthcare system works from both sides of the fence, working for an insurance company is interesting.
Medical Billing Services
Some healthcare providers prefer to separate the business and medical aspects of their practice by using third-party billing services. These companies employ medical billing and coding specialists to manage claims for hundreds of doctors and medical facilities.
It’s a busy, business-like setting without the exposure to clinical issues that you’ll get at a hospital. You’ll work with administrators, accountants, and other financial professionals to:
- Complete claims
- Investigate denials
- Invoice patients
- Process payments
- Handle client and patient inquiries
- Produce financial reports
Government Insurers and Public Health Agencies
The Centers for Medicare and Medicaid (CMS) is the nation’s largest insurer. It makes many of the rules that commercial insurers adopt. Working with local branches, you’ll learn a lot as a medical billing and coding specialist. Jobs are like those at any insurance company but with a strong research component.
CMS partners with public health agencies to conduct disease surveillance. It’s how they forecast trends in community health. Essential to budgetary planning and resource allocation, it’s a critical role.
Responsibilities on the insurance side include processing claims with an emphasis on proper coding. Collating codes is how agencies like the CDC gather health data. Jobs in public health are research heavy. You might, for example, investigate how many people in specific states have a diagnosis of diabetes so that officials can plan intervention programs.
Pharmacies and Medical Equipment Vendors
Pharmacy benefits are a complex part of health insurance policies. Most companies have adopted a tiered system in which different drugs have separate copayments. And some ask patients to try certain medications before approving higher-priced alternatives. Patients suffering from migraines, for example, may have to show that over-the-counter analgesics, such as ibuprofen and naproxen, were ineffective before resorting to prescription drugs.
Pharmacies hire medical insurance billing specialists to manage these claims, streamlining the communication process between providers and insurers. It’s a lot of paperwork, but it helps patients access the medications they need without delay, and for the lowest possible price.
Similarly, medical equipment vendors employ medical billers to preauthorize purchases and submit claims for products, from walkers to wheelchairs. Most are covered by insurance, but the rules are convoluted and often too complicated for patients to navigate without professional guidance.
Working in a pharmacy or medical equipment store is a good way to connect with people if you enjoy serving the public. Applicants with prior retail experience can climb the career ladder quickly in this setting.
What Will I Learn in a Medical Insurance Billing and Coding Program?
A Medical Insurance Billing and Coding program prepares students for entry-level employment in any setting.
Courses include:
- Billing Basics
- ICD-10 Coding
- CPT/HCPCS Coding
- Advance Clinical Coding
- Inpatient Coding
- Coding from Operative Reports
Graduates are eligible for many of several industry certifications, a plus in a competitive job market.
Final Thoughts
As other careers vanish, jobs in the medical field remain plentiful and secure. The US Bureau of Labor Statistics projects strong growth throughout the healthcare sector in the coming decade. A passion for health, good organizational skills and the right vocational school program will help you succeed as a medical insurance billing and coding specialist.
Want to Learn More?
Ready to attend the Medical Insurance Billing & Coding program at Meridian College? Medical Billing and Coding professionals are responsible for keeping the records, charts, and bills in a medical office in order. In addition to the classroom experiences, students will also complete an externship for on-the-job training that will bring them further expertise.
Contact Meridian College today to learn more about becoming a medical billing and coding specialist.