Medical Billers and Coders: An Integral Part of the Healthcare Industry

You went to the doctor, you gave them your insurance card, and a few weeks later got a bill in the mail for what insurance didn’t cover. What happened in the middle?

Medical billers and coders play a vital role in the system connecting health care providers, the patients they serve, and insurance companies that reimburse medical expenses. 

One of the most crucial tasks performed by medical billers and coders is reading patient charts to determine medical history, including diagnoses and treatments given. Based on these charts, and a set of established medical codes, the medical biller and coder will transcribe patient history into an abbreviated format that is used by insurance companies to determine reimbursement. 

The everyday function of a medical biller and coder includes properly coding any services, procedures, diagnoses, or treatments carried out by the practice. A medical biller and coder will also likely prepare and send invoices or claims for payment.  In this article, we will discuss the steps in the medical billing process and the possible consequences if there are errors.

The standardized CPT and ICD codes are used by health care providers, hospitals, insurance companies to track and record the details of a patient’s visit and make sure that claims are processed properly. Each code has guidelines on how it can be used, and the penalty is steep for knowingly falsifying a code that will cause the insurance company to reimburse the facility at a higher rate than the service or treatment performed.

Medical billers and coders are sometimes combined in the same role. When they are not, the medical biller uses the shorthand from the medical coder and submits claims to the insurance company. The biller will then follow up with both the insurance company and the patients, making sure timely payments are made so that the medical practice receives compensation and the patient is billed appropriately.

The information in the transcript of codes is submitted to the patient’s insurance company as a claim and the insurance company pays a certain amount to the healthcare provider based on the codes listed and what the patient’s plan covers.

After the insurance company pays their portion of the cost, the remaining amount is billed to the patient. Co-pays and deductibles the patient has paid are figured into the revised amount to pay. Accuracy is just as important in medical billing as in medical coding because it directly affects the amount the patient will pay, and there is ample opportunity for conflicts to arise from errors.

Medical coding and medical billing are two facets of an important checkpoint in the healthcare system to make sure that health services are being reported accurately, that information is given to the insurance company, and a true and correct final invoice is sent to the patient. Both jobs are very important to ensure that the health care facility is reimbursed correctly.

The consequences of errors in medical billing can have far-reaching effects. When a code is not entered properly by the coder, it is passed on by the biller to the insurance company. As mentioned above, there are hefty consequences for knowingly using the wrong codes to overbill insurance, but what about other mistakes and oversights?

If your claims are part of ongoing litigation, you want to make sure that every piece of your treatment was billed properly. If you were overbilled and the settlement will only pay for the treatments you should have received, this can mean a lot of money out of pocket for you.

Not all medical billers and coders are familiar with the unique challenges inherent in analyzing injury claims or projecting future costs, and if this is a concern then you should make sure that a medical billing and coding company is involved to look over the bills and ensure everything is in place. 

Medical billers and coders are not responsible for patient care, but a working knowledge of medical terminology and the ability to discuss the details of medical bills with carriers and patients is vital. In some circumstances, it is worthwhile to have a medical biller and coder who can prepare an expert witness report that can be used if the medical treatment was part of an injury or accident case and there are legal proceedings involved.

It is highly recommended that a medical billing company is used to determine and testify to the reasonable value of medical service.  The provider’s location can affect these costs and reimbursements, which is why Medical Billing Analysts is a perfect choice, with offices around the country.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in cases where healthcare costs are being argued is the topic of medical bills. Figuring out medical costs can be a difficult prospect, and having a medical billing and reimbursement expert to offer guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review bills from the hospital, outpatient treatment, and therapy in order to determine the total costs of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of ongoing costs.   Through meticulous analysis, we can offer an estimate of how many medical costs will be in the future, to help justify the reasonable cost of services that assists in resolving the case.

You can reach Medical Billing Analysts by phone or email at 800-292-1919 or intake@medicalbillinganalysts.com . We’re ready to handle your medical billing needs, regardless if you need a single charge to be evaluated or if you are involved in litigation in a complex case, where injuries are just a part. Contact us today.