What Does A Medical Billing Specialist Do?

The most important behind-the-scenes process in every medical facility is medical billing and coding for patient invoices and insurance. But who are the individuals who complete this task?

In some cases, office managers and physicians may stretch themselves thin by taking on this role.Typically, medical providers will hire a medical billing specialist or a medical coder to fulfill this role. 

That way, physicians can focus on providing the best care possible while trained specialists take on the most important administrative role in the ecosystem of a medical institution.

Here’s a detailed breakdown of the medical billing specialist (aka medical coder) role. 

The Role Of Billers And Coders

A medical billing specialist bridges the gap between a medical institution and insurance companies. In other words, this individual manages payments, invoices, and insurance claims on the behalf of the organization they work for.

Billers and coders usually do the following:

1. Code services, diagnoses, treatments, and procedures

2. Prepare and send out invoices and payment claims

3. Correct rejected claims and track payments

4. Communicate with insurance companies and patients to receive outstanding bills

Even though these professionals work in the same facility as physicians, most patients will never come in contact with them. It’s purely an office job that takes place in the background. 

Are Coding And Billing Different?

While the job description is similar and a medical billing specialist may also do coding, the positions are quite different and have unique sets of responsibilities.

With small medical offices, it’s standard practice to hire either specialist to perform both roles. In larger facilities, the roles are separate and both coders and billers work together to ensure the process of coding runs smoothly. This also helps medical providers avoid costly billing and coding errors whileensuring payments are collected on time.

In a larger facility, the division of labor between the two may look something like this:

Medical Coders

The main responsibility of coders is converting procedural and diagnostic notes into codes for billing and record-tracking purposes. These are industry-standard codes that identify provided and billed medical services.

Medical coders require a different set of knowledge of the following codes:

1. International Classification of Diseases (ICD-10) - classification of medical diagnoses

2. Current Procedural Terminology (CPT) - codes that identify procedures and examinations, and are updated annually

3. Healthcare Common Procedure Coding System (HCPCS) - codes not included in the other two sets of codes that normally cover non-physician services, medical supplies, and devices

A coder may enter these codes when a patient books an appointment. Then they’ll code for the symptoms and the type of visit. Afterward, they will apply additional codes for symptoms described by physicians, as well as tests, diagnoses, procedures, and recommended treatments.

Medical Billers

After coders have completed their job, medical billers take over. They generate invoices and send the claims to payers. Insurance companies will then approve or deny the requests based on the provided codes. The costs not covered by insurance are then forwarded to the patient.

The billing process itself starts when the patient makes an appointment and billers submit codes for pre-approval. This is done to determine the patient’s out-of-pocket expenses, allowing the medical provider to charge the amount during the visit.

The reason why a medical billing specialist is often interchangeable with the coder is the fact that the biller also needs a deep understanding of industry codes. Even in cases where the roles are separate, the biller is in charge of updating the codes and reviewing the reasons behind denied insurance claims. More importantly, they also need to verify if the codes are correct before filing any claims.

Furthermore, the medical billing specialist is in charge of invoicing patients when insurance billing is complete. They track payments, follow up on due payments, and determine copay amounts and requirements.

If the bill is unpaid, billers have to reach out to insurance companies to check if the paperwork requires updating. They’ll also reach out to patients if they failed to submit payments for outstanding bills within a specific timeframe.

Required Skills

The basic requirements for both roles are generally  the same. The most important skill is deep knowledge and experience with up-to-date codes. There are additional skills that help distinguish a bad specialist from a good specialist, such as:

1. An understanding of medical terminology

Coding and billing are significantly easier when the staff is familiar with basic medical terms. This may include knowledge of physiology and anatomy terminology, as well as familiarity with procedural and diagnosis terminology. 

2. Mathematical skills

Medical coding is all about numbers, so it’s essential to be able to do basic arithmetic calculations to calculate the right billing amounts. In today’s day and age, we have access to billing software systems that automatically fill out the forms with correct amounts based on the medical codes. However, this doesn’t mean there are absolutely no calculations. Medical billers, for example, usually manually calculate the patient’s amount of due payments or quantify payment plans.

3. Computer skills

To be able to successfully fulfill these roles, coders and billers need to know medical software and computer systems used in medical institutions. They also must learn to use new software fast in case there’s an upgrade or switch.

4. Communication skills

In addition to the above, medical billers need to possess a high level of communication skills since their tasks include contacting patients and insurance representatives. They should be able to effectively communicate with patients who may be going through a lot of stress when dealing with their medical bills.

Medical Billing Specialist As An Expert Witness

Medical billers and coding specialists may also offer their services as expert witnesses. They can provide expert opinions in cases of Medicaid and Medicare abuse and fraud, along with reviewing bills and records to determine if the charges are reasonable. 

They may also put together witness reports about all sorts of billing claims, and explain benefits and copays.

Both plaintiffs and defendants can leverage the services of these experts to determine the right costs of medical care, and ensure the jury and the judge have the right understanding that the charges are fair and reasonable.

Why Go For Medical Billing Analysts?

If your case involves any dispute over medical billing codes, you should hire an expert that can provide you with an evaluation of your medical charges. 

With an MBA on your team, the discovery and research during your complex medical phase will go a lot smoother. You can focus on the fine legal details while we analyze the medical bills and help determine the fair and reasonable charges.

Contact MBA now by calling (800) 292-1919, and build a stronger case!