Both Medicare and private insurance plans use many different methods to identify and avoid incorrect or improper payments. The methods and tools used can vary depending on the review type, and whether they are used in the pre-payment or post-payment stage. 

Both are important, but understanding pre-payment review is the first step in understanding the beginning of the payment review process. Pre-payment review in particular can help prevent improper payments, saving money from day one.

What Is Pre-Payment Review?

The Medicare insurance pre-payment review is a simple step in the claims process. It is the review of a claim before it is paid by the insurer. In some cases, the pre-payment review can result in the denial of the payment. The pre-payment process includes medical review as well as the application of edits where needed. An edit can provide automatic verification of certain claim details, even across sets of claims, so make sure they meet the criteria for payment. Edits are applied by processors between submission and payment of claims.

When Is Pre-Payment Review Required?

Pre-payment review is when Medicare, or potentially any private insurer, wants to review all of the claims from a particular office or facility before they pay them.

This often happens when using a doctor, facility, or office that has had a history of claims that resulted in improper payments. In many cases this could be because they’ve submitted documentation that doesn’t support the coding, unnecessary services, billing inconsistencies, and more. Sometimes, payers determine that there is an anomaly in claims that is traceable to other providers in the region.

What Is The Pre-Payment Review Process?

In general, there are two primary types of pre-payment reviews, the complex, and the non-complex. The complex review is going to require documents aside from the claim itself, such as medical records or consultation to review the validity of the claim. The non-complex review isn’t going to require any additional documentation.

There are three criteria on which reviews are based. These are National Correct Coding Initiative edits, edits classified as Medically Unlikely, and Medical Review. Both the National Correct Coding Initiative edits and Medically Unlikely edits will generally be non-complex reviews.

Medical review, however, can be a relatively complex process. It will usually be performed by Medicare Administrative Contractors or Supplemental Medical Review Contractors, and the review contractors will focus Medical Review activities specifically on the already-identified problem areas, and will determine the action to take based on the severity. These actions can include:

• Pre-payment review
• Post-payment review
• Education or feedback for the healthcare provider

If the decision made is to enact pre-payment reviews, the insurer or payer will ask the provider to send pertinent records and other documents for any claims made within a predetermined time frame. In many cases the records period is three month’s worth, but in some rare cases they can go much further back.

Ending Pre-Payment Reviews

To remove pre-payment reviews, providers or coders should first review all of the pertinent medical records and double-check that all codes used are supported by the medical records. Additionally, they should make sure that their billing and coding department is adhering to the requirements of each insurer when actually assigning codes or creating billing claims. Coding and billing staff should also be trained to properly check for bundling and unbundling of codes.

AMS Solutions Can Help Prevent Pre-Payment Reviews

When it comes to preventing or avoiding pre-payment reviews, AMS Solutions can provide coding and billing professionals that are kept up-to-date and completely educated on all aspects of claims billing.

What Is Concurrent Review By An Insurance Provider?

Many people wonder what the standard concurrent review definition is. A concurrent review is a review that takes place while the patient is actively receiving care during an admission to a healthcare facility. The concurrent review’s purpose is to have some framework for oversight during treatment that allows examination and scrutiny of the type of care that is being administered to the patient. It also evaluates the necessity for that level of care, as well as the setting.

Why Are Concurrent Reviews Needed?

The goal of concurrent reviews is to make sure that healthcare is delivered effectively and efficiently, to reduce or prevent the improper use of inpatient medical services and treatment, and to ensure that all patients receive the high quality of care that is indicative of inpatient treatment. It works similarly to prior authorization, in that the concurrent review can help foster more effective communication about the patient to various areas or departments of the healthcare organization itself. 

Additionally, concurrent reviews also help provide access to other health services and support features that may help with the coordination or continuation of care, particularly in regard to transitions from one level of care to the next. This may be either discharged to a care facility, or even to their home. A concurrent review is also able to identify patients that may benefit from various care methods, including case or disease management, or any number of other options depending on the diagnosis and treatment needs. 

The Concurrent Review Process

The concurrent review process is designed to optimize care during a hospital or treatment facility admission. The goal is to ensure that the patient receives the right care, right when it’s needed and that the treatment is in line with the insurance plan and coverage requirements. The concurrent review process includes aspects such as:

• Collection and aggregation of all patient information directly from the care team regarding their condition and progress in treatment
• Evaluating patient treatment information from the care team to determine treatment coverage
• Maintaining informative communication between all parties involved in the patient’s care when a decision regarding coverage is made
• Identifying situations when patients may be given a discharge and continuing care plan early in the stay
• Continual evaluation and assessment of the care plan during the stay
• Identifying and referring any potential concerns about the quality of care or patient safety that may require additional review

Concurrent Review vs. Peer Review

A concurrent review is functionally much different than a peer review when it comes to the process by which they happen, as well as the goal of each. The concurrent review process is an ongoing process that should be happening seamlessly as a part of all levels of care for an insured individual. 

The peer review process, however, is meant to address specific and often highly complex treatment needs on an ad hoc basis. This process consists of any current treating practitioner submitting a request to consult with a medical health professional within the insurance company. Often this is to discuss a utilization issue or to go over needed care that may be required for long-term care services and other continued care support services.

AMS Solutions Can Optimize Your Coding For Review

One of the biggest factors in ensuring your organization is paid promptly and correctly is leveraging expert billing and coding professionals. With more than 30 years of experience in the billing, collections, credentialing, and practice management fields, you can trust that AMS Solutions will be an effective coding and management partner. 

If a healthcare patient’s claims are denied, not only will they often wonder why claims are not being processed, but they may still submit claims that are inaccurate. Here are some of the common reasons that claims are denied.

Top Reasons Why A Claim Is Not Being Processed

Missing Or Incomplete Patient Info

An incredible portion of claim denials are administrative or clerical in nature and originate at the front desk. This means things like patient data oversights, such as a missing patient subscriber number, missing date of birth, and incorrect insurance eligibility are all routine reasons that a claim is denied. 

Basic Claim Form Errors

A huge portion of claim rejections is known to be caused by “simple errors” in either the patient data or in the procedure codes. This can be something as simple as a misplaced letter in the last name, or a patient ID number having two digits transposed. These errors are usually very quick and easy errors to fix, but they stretch out the revenue cycle, so they should be avoided if at all possible. 

Lack Of Official Documentation Supporting The Claim

Claims that have a component of medical necessity will need documentation or records that support that designation. In situations like this, the payer will often require additional support documents that not only illustrate medical necessity but also support the level of service.

Insufficient Medical Necessity

Even when substantial amounts of documentation and medical records are provided, occasionally a payer will simply decide that a procedure or treatment isn’t medically necessary. This can be a difficult situation for everyone involved, but in some cases, it can be avoided. 

 

The best way to fight insufficient medical necessity denials is to have good communication between your clinicians and coding staff. When a claim is denied, for this reason, the doctor’s office or provider may be forced to absorb the treatment cost, or they may be able to collect the full amount from the patient, which isn’t very likely. 

Pre-Authorization Or Pre-Certification Was Not Obtained

There are many situations that warrant getting pre-authorized to perform some type of care. Knowing which insurers require pre-authorization and what they require to authorize coverage is essential for your coding and billing team. Depending on what coding or billing software is used, there may even be built-in measures for highlighting certain procedures and special insurers.

Claims Filed After Deadline

With all of the different insurers out there, it’s no surprise that many of them have different deadlines for submitting claims, and have varying degrees and policies for exceptions when deadlines are missed. Some payers can fix a missed submission with a quick phone call, while others will require a more clerical and administrative fix by having you fill out some paperwork to get the issue fixed.

The Provider Used Was Out-Of-Network

Insurance companies and their networks can change drastically from one year to the next, and while many patients don’t realize it, this includes the various doctors and healthcare providers they have partnered with. To be sure that claims, benefits, and payments are made in full for your treatment and doctor’s appointments, use a doctor or facility that is in-network. While this may not mean that everything is covered, significantly more of the services that you need will be able to be obtained in this way. 

Prevent More Denials With AMS Solutions

Your billing matters and claims denied for simple and preventable mistakes. Ensure that your medical billing support is all properly trained in the methods that your biggest payers require by partnering with AMS Solutions.

Everyone needs healthcare at some point in their life. The article is intended to assist you in understanding the different types of health insurance plans that are available, and how to choose the one that will be best for your patients. It is essential for everyone to fully understand this topic as it can make a big difference for your patients and their families.

What Is Health Insurance and Why Is It Important?

Health insurance is a type of insurance coverage that helps to protect an individual against high, unpredictable costs of medical care. It is designed to cover a person’s medical expenses and can be used in conjunction with other types of insurance, such as life insurance and disability insurance.

Healthcare coverage is important because it provides protection for the insured person when they are ill or injured, which can be expensive. Without health coverage, you may have to pay all your medical bills out-of-pocket or go into debt if you cannot afford treatment. This isn’t what most patients who need healthcare want. 

As a healthcare provider, you want to ensure your patients have options when it comes to what insurances you accept.

What Are Different Types of Health Insurance?

Health insurance is a type of insurance that covers the cost of medical expenses. In the United States, health insurance is provided by private companies and individuals, with most Americans receiving their coverage through their employers.

Many different types of health insurance plans are available to consumers in the United States. These plans include:

• Individual plans
• Family plans
• Medicare Plans
• Medicaid Plans
• Military Health Benefits

There are also two different types of health insurance plans: HMO and PPO. An HMO plan limits a patient’s choice of providers, while a PPO plan allows patients to see any doctor they choose.

Some people prefer an HMO because they have lower monthly premiums, but they usually have higher deductibles and copays than a PPO plan.

How to Choose the Best Health Insurance for Your Practice?

Medical insurance is one of the most important aspects of any medical practice. It makes it possible for a provider to provide their patients with the best care possible and ensure that they have access to all necessary treatments. Without this, many practices would be forced to close their doors for good.

There are many different types of health insurance, each with its own pros and cons. The best medical insurance for doctors will depend on their individual needs and goals for their practice. For example, if a doctor wants to have the freedom to focus on patient care without worrying about the financial ramifications of running a business, they might want to try a concierge-style plan where they are only accepting so many patients each year. 

Every practice varies on what insurances they accept. What insurances you want to work with depends on what kind of work you do and how you want to run your practice.

Let AMS Solutions Help Your Practice

AMS Solutions is a leading provider of best-in-class medical billing and coding software. Founded in 1998, AMS Solutions has been providing top-quality products to the healthcare industry for over 20 years.

We are a company that provides a variety of services to help practices and hospitals automate their billing and coding processes, streamline the revenue cycle management process, and maximize reimbursement potential. We are known for utilizing cutting-edge technology solutions in order to make these tasks easier, saving time, and improving quality.

Contact us today if you are looking to contract with insurance companies! We have helped a number of healthcare providers and practices get the coverage they need so that they can focus on what matters- providing high-quality care to their patients.

Medical insurance in America has always been an uphill battle. Over the last decade, the number of uninsured or underinsured Americans has skyrocketed to 48 million. Even with President Obama’s Affordable Care Act, many Americans still struggle to afford their monthly premiums.

The Current State of Healthcare in America

The United States is the only advanced economy that lacks universal healthcare coverage. Despite this, the U.S spends more on healthcare per person than any other country in the world. The costs of healthcare are spiraling out of control, with no end in sight.

The medical insurance landscape has changed significantly over the past decade. The Affordable Care Act, also known as Obamacare, was passed in 2010 and it helped to change the landscape by requiring Americans to have health insurance coverage. Before this law was passed, people could go without coverage and not pay a fine if they didn’t have it.

The Affordable Care Act also required that insurers offer ten essential health benefits, including maternity care and mental health care. This meant that some plans had to cover these things that they never had before which caused many people to lose their previous plans because they didn’t offer these benefits.

How the Affordable Care Act Affected the Medical Insurance Landscape

The Affordable Care Act was a law that was passed in 2010 and went into effect in 2014. The goal of the act was to provide affordable health care coverage for all Americans. The ACA did this by creating exchanges where people could purchase private insurance, expanding Medicaid eligibility, and providing subsidies for those who couldn’t afford insurance.

The Affordable Care Act has had a huge impact on the medical insurance landscape. In states that did not expand Medicaid coverage, there has been an increase in the number of uninsured people, which has led to more emergency room visits and hospitalizations as these individuals wait until their conditions are severe before seeking treatment.

This act has also contributed to the rising cost of medical care in America. The ACA has increased the number of people who are insured and as a result, demand for services has increased. Furthermore, an aging population and the spiraling costs of prescription drugs have also been factors contributing to escalating medical costs.

The Future of Healthcare in America

The healthcare system in America is changing drastically. The US government has been trying to make changes to the system for a long time, but with no success. Recently, they have been trying to repeal and replace Obamacare with a new health care bill, but it hasn’t gone through yet.

The future of healthcare in America is dependent on the future of the Affordable Care Act. The Affordable Care Act has been a major player in the healthcare sector’s growth and development. The ACA has helped to expand coverage, reduce costs, and lower financial burdens on individuals.

What will happen if this law is repealed? We can only guess what will happen but it’s safe to say that the future of healthcare in America will be drastically different than it is today.

Employee Assistance Programs provide emotional help for employees through counseling, education, and other services. However, the different types of companies vary in the specifics of what they offer and how to find the right one for your company. It’s vital to know what you’re looking for before committing to any specific program.

The Importance of an EAP Provider

Employee Assistance Programs (EAPs) are a valuable resource for employees and employers alike. EAPs provide employees with confidential, professional, and affordable assistance in the event of a personal or family crisis. EAPs provide employees with confidential, professional, and affordable assistance in the event of a personal or family crisis. EAPs offer many benefits to employers as well. For example, some EAPs can help reduce absenteeism by providing short-term counseling services to employees who are experiencing personal issues that may be affecting their work performance. In addition to this, some EAP providers can offer benefit coverage for mental health services that would not be covered under an employer’s insurance plan. This is especially helpful since many mental health disorders are not covered by most insurance There are many different types of crises that can happen in the workplace, such as:

• Mental health issues
• Substance abuse
• Financial problems
• Family emergencies
• Legal difficulties

How to Choose the Right EAP Provider for Your Company

The EAP provider chosen for your company should be the one that provides the best mental health benefits and is competent in providing the necessary services for your employees. An EAP provider should have a team of experts who are trained to work with various kinds of emotional issues, such as depression, anxiety, marital problems, substance abuse, and many more. You must choose an EAP provider that can offer you a variety of mental health benefits like counseling sessions, employee assistance programs (EAPs), and alternative therapies.

What are the Different Types of EAP Providers?

EAP providers are companies that offer Employee Assistance Programs. They provide assistance to employees in the form of counseling, referrals, and other forms of support. EAP providers can be in-house or outsourced. In-house EAPs are offered by the employer themselves whereas outsourced providers are contracted by employers to provide the same service. Outsourcing is a popular option for small businesses that cannot afford to have an in-house EAP or for large companies with multiple offices across the country. The advantage of outsourcing is that it provides a more personalized approach to dealing with issues as well as an increased level of confidentiality for employees seeking help from them.

How to Evaluate a Potential EAP Provider’s Services and Programs?

EAPs provide a range of services and programs to help employees with mental health and substance abuse issues. Evaluating an EAP provider’s services and programs is the first step in the process of deciding which one to choose. The following are some essential factors that you should consider when evaluating an EAP provider: The number of years in business The level of education and experience of the staff The type of treatment they offer Their success rates Their prices

How to Find the Best EAP Provider for Your Company

AMS Solutions has an expert team of professionals who can help your company find the perfect Employee Assistance Program (EAP) provider. We have strong relationships with all the major EAP providers and are able to offer expert advice on what is best for your employees at every stage of employment. We have a wide range of EAP services that are tailored to your company’s specific needs. When you are ready to hire an EAP provider, contact us! We make the process easy and simple. We even offer free practice audits!

Healthcare providers venturing out into private practice often don’t know how to deal with the process of getting paid for services. They’re understandably unfamiliar and can feel a sense of confusion surrounding billing and insurance. Healthcare providers are typically not taught about healthcare billing in their training, so this is an area that needs to be addressed in order to succeed in their offices. 

Creating a revenue cycle for your practice can be a difficult process, but with some advance planning and a bit of research, you will feel much more confident about the entire process.

First things first, you need to understand the difference between in-network and out-of-network insurance companies, how they operate, and why it’s integral to have insurance credentials. Without insurance credentials, you won’t be paid for the medical services you provide to your patients. 

What is the Difference Between In-Network and Out-of-Network Insurances?

Health insurance is an important topic for many people. However, it can be tricky to understand the difference between in-network and out-of-network coverage. It’s easier to comprehend than you think. When patients find you, you’ll either be in-network or out-of-network. 

In-network coverage is when a person goes to the healthcare provider that they have chosen to be in their network. This means that they will not have to pay any more out-of-pocket expenses for the medical care that they receive. As a provider, you want to be in-network with as many insurance companies as possible. Patients prefer to go to providers that are in-network. 

Out-of-network coverage is when a person goes to a healthcare provider outside of their network. This means that they will have to pay more out-of-pocket expenses for the medical care that they receive. Patients are less likely to go to providers that are out-of-network. 

Why Is Insurance Credentialing Important?

The credentialing process for insurance is an important process for a number of different reasons. For starters, it ensures that the person applying for a license is qualified to do so. 

This can reduce instances in which unqualified individuals represent themselves as licensed professionals, which in turn can provide consumers with false information and potentially cause them to make bad decisions. 

You should consider what insurance companies you would like to contract with. Some major insurance companies are Blue Cross Blue Shield (BCBS), Medicare/Medicaid, United Healthcare, Cigna, and many more. You will have to fill out an application for each insurance company that you want to be in-network with. 

These applications can easily take around 2-6 hours to complete. This is where a medical billing company can provide some assistance. Hiring a medical billing company can help you with insurance credentialing applications and speed up the complicated process. 

Get Professional Streamlined Medical Credentialing 

Credentialing with insurance is a lengthy, time-consuming process. If you’re looking for professional streamlined insurance credentialing, you’ve come to the right place. Here at AMS Solutions, we take medical and insurance credentialing very seriously. 

AMS Solutions is a leading provider of credentialing services in the insurance industry. No matter what insurances you are looking at, we’ll make sure you get contracted with them. 

Let us take care of all of your medical credentialing needs with quickness and efficiency. We know you don’t have the time required for proper medical credentialing, which is why we’re here to save you time and money. 

Send us a quick message here, or feel free to call us anytime at 214-522-0210. We’re so excited to hear how we can help you and learn more about your private practice!

We also offer free practice audits for your convenience. 

Getting a recoupment request can be scary and worrisome. Recoupment is a provision in most health insurance policies that allows the insurer to request a repayment of some or all of the cost of care after it has been provided. Most insurance companies have this provision, but it is not often used. 

Companies may also request repayment for certain services when they do not agree with the treatment they provided. There could be disagreement over in-patient and outpatient treatment, as well as disagreement over the use of imaging services and lab tests that were provided. 

If you need help with combatting a recoupment request, you may want to seriously consider getting a medical biller to help with the appeal process. 

What Exactly Is Recoupment?

As aforementioned, recoupment is a term used in the insurance industry to describe the process of recovering money from a third party.

The term is most commonly used in reference to health insurance, but can also be applied to other types of insurance policies. In the insurance industry, recoupment is a process wherein an insurer recovers money from a third party. 

This process can come as a result of either legal action or voluntary payment. Recoupment is often used to cover losses that occurred due to an accident between two parties. Hiring a medical billing company can help you fight any recoupment request. 

Common Reasons for Recoupment Requests

The recoupment process starts with a written request for repayment. This will be accompanied by a phone call or email to alert the medical insurance provider that there was an error. 

Just about every insurance company will give you up to 30-60 days to take action once the initial request has been sent and delivered. There are many reasons why a recoupment request can occur. 

The most common reasons for recoupment requests are:

• Duplicate payments for the same service code/date
• A duplicate claim was submitted in error
• Payment sent to an incorrect healthcare provider
• Payment for a service that happened after the patient’s insurance plan expired
• Payment made for a supply or service that was not covered in the patient’s insurance plan
• The insurance claim was paid for an ineligible beneficiary 
• The patient’s total deductible was miscalculated

How To Fight A Recoupment Request 

As a healthcare provider, there are ways you can fight a recoupment request if you believe it’s not valid. One of the first steps you need to take is to ask for all relevant documentation from the insurance company relating to the patient’s claim and the recoupment request. This ensures that you have followed guidelines by verifying the payment against established contract guidelines.

If you have received a contested recoupment request, it’s important to get in touch with your state insurance commissioner as soon as possible. The state insurance commissioner is the best person to ask about the rules and regulations for this type of situation.

There are some states with firm timelines for recovering returns which can affect how the process goes if a breach of contract occurs later on. When analyzing these documents, be sure to look for those areas where the breach happened. It’s crucial to assess which party should be responsible for the compensation and know how much of the agreement needs to be fulfilled financially.

Avoiding Recoupment Requests

The practice of recoupment is typically done by collecting money from the patient or their family. There are many ways to avoid this situation, but one of the most important things to do is to hire a medical billing company for your office. They will not only handle all the billing, but they will also make sure that you don’t get any recoupment requests in the future.

This is where AMS Solutions comes in. The best medical billing company in Texas is AMS Solutions. We have over 20 years of medical billing experience and know exactly how to maximize your profits as a healthcare provider.  

Get a free practice audit today! 

You can also call us at 214-522-0210 or email us at info@ams-solutions.com. 

The medical billing process is typically long and complicated. It can be difficult to keep track of all the details and make sure that you are following the right steps. There are many mistakes that can happen during this process, which can lead to a patient’s account being sent to collections.

In this article, we will go over the most common medical billing mistakes and how you can avoid them so that your patients don’t end up with a bad credit score or a debt collector knocking on their door.

What Are Common Medical Billing Mistakes?

Medical billing mistakes can have disastrous consequences. Whether the mistake is with your patient’s personal data or the insurance code, a medical billing mistake can result in some very harsh consequences.

The 4 most common medical billing mistakes are:

1. Unbundling

It can sometimes be hard to tell when certain services should be billed together and other times it is not, often resulting in a higher total claim. Avoid this by always bundling services done at the same appointment.

2. Incorrect Billing

Incorrect billing is when a medical practice charges a patient for incorrect services or for services that they never received. Incorrect billing can also happen when a member of the staff inputs incorrect patient or provider information. 

3. Duplicate Billing

Duplicate bills often happen when someone accidentally sends the same bill twice. It could be that they failed to notice they already sent the claim and sent another, or it might mean there are duplicate procedures in a patient’s records.

4. Upcoding and Undercoding

If you don’t include a medical billing code for less expensive procedures, it can happen for a few different reasons. What matters most is that under coding always appears suspicious and your office can get into trouble – same with upcoding. 

Many medical facilities are faking the severity of procedures they offer in order to receive higher payments. This is the definition of upcoding and it’s a form of fraud that can lead to significant financial losses.

Hiring a medical billing company can prevent many of these common medical billing errors. Medical billing companies use billing software that effectively minimizes the chances of medical billing mistakes. These billing mistakes can ultimately have a negative effect on your office and your patients. 

How Billing Mistakes Negatively Impact Your Office

If you think making medical billing mistakes won’t impact your office, think again. This is what can happen when you consistently make billing mistakes:

• Hiring Extra Staff = Extra Expenses 

When a mistake is made in the medical billing process for your office, you’ll have to hire additional staff in order to fix the mistakes and current workload. This means extra expenses that wouldn’t have needed to be spent if the mistakes were avoided in the first place. 

• Delayed Payments 

The delayed billing caused by your remittance process makes it more difficult to project cash flow, as you can’t reliably know when revenue and expenses are expected to come in. This means that while the delays may be reasonable, this only complicates things when you need to explain why your rent is late or tell the insurance company that you are behind in processing payments. 

• Stressed and Confused Patients 

Explaining medical billing to a patient can be tricky, especially when it comes to medical billing errors. Someone who is sick or unable to work (because of an injury) may be worried about having to pay for their doctor’s visits and treatment. An unhappy patient is more likely to share their grief with family and friends. Negative word of mouth is the last thing you want for your office. 

• Unsatisfactory Revenue Cycle Management

The revenue cycle typically starts when an appointment is booked and concludes with the bill being paid in full. A short cycle is best while long cycles may indicate problems in your office’s revenue cycle. 

All of these mistakes can be avoided when you take the proper precautions and you have a professional medical billing company working for your office. 

How to Prevent Medical Billing Mistakes with Our Medical Billing Company 

Medical billing is a tedious process for medical providers, but with the help of AMS Solutions, it doesn’t have to be. Our comprehensive medical billing company provides a wide array of billing services for all medical providers. No matter what you need from us, we’re ready to tackle it!

We even offer a free practice audit! 

Contact us today to get yours. You can also call us at (214) 522-0210. 

Without the help of a medical biller, healthcare professionals are at risk of falling behind in billing their patients for office visits. Falling behind in billing your patients can mean a loss in total revenue. For this reason, medical billing is an integral part of every medical office. 

When a doctor’s office bills a patient for an office visit, the medical biller has to submit a claim through an insurance company to receive payments for the services rendered. Medical billing doesn’t just include data entry – it takes customer service skills, attention to detail, and expertise in health insurance.

Many doctors don’t have time to take care of medical billing. That’s why every medical office should hire a medical billing company. Medical billing companies are the backbone of every doctor’s office. Medical billers and coders are there to help you get the most revenue you can out of your healthcare practice.

What Does A Medical Biller and Coder Do?

The most commonly asked question is: what exactly does a medical biller and coder do? Does a medical biller and coder do different tasks than just a medical biller? 

In a nutshell, a medical biller does the hard work of dealing with insurance claims. It’s more than likely the average healthcare professional doesn’t have time to deal with calling insurance companies and checking on the status of a claim. Medical Billers are also the ones who follow up with patients that have past due balances on their accounts.

A medical coder uses a coding textbook to code for the type of office visit that occurred. A skilled coder will be able to code quickly with minimal to zero errors. Most reputable medical billing companies will offer both medical billing and coding services.

Medical billers and coders can specifically deal with the ins and outs of healthcare insurance. They have extensive knowledge about insurance that healthcare professionals don’t have the time to learn. 

Why Should I Hire A Medical Biller and Coder?

After dealing with patients all day (and sometimes all night), no healthcare professional wants to sit down at a computer and do a ton of billing work.

To put it simply, when you bring in a medical biller and coder, you’re taking the first step to maximizing your profits as a medical business owner. Not only do billers and coders help you with receiving payments from insurance companies and patients, but they can also give you aging reports to assess how your business is doing financially. 

Medical billing and coders are usually the ones who perform a follow-up call when a patient has an overdue balance on their account. Basically, they deal with everything and anything to do with medical office finances. If anything is not right with your finances, a medical biller and coder will catch it. 

What Qualities Does A Good Medical Biller and Coder Have?

A quality, professional medical biller and coder will have either a certification, a degree, or a combination of the two. There are multiple kinds of medical billing and coding certifications that a potential employee can have – which ones you’ll prefer depends on what skills you are looking for. 

Hiring the right medical biller and coder for your company means hiring someone who has the required education and background to fill the role. 

Common Medical Billing & Coding Certifications

• Certified Professional Coder (CPC)
• Certified Inpatient Coder (CIC)
• Certified Billing and Coding Specialist (CBCS)
• Certified Coding Specialist (CCS)

Checklist for a Good Biller/Coder

• Has a professional degree or certification
• Has relevant experience
• Has references to call upon
• Knows how to use medical practice management software
• Knows all the billing and coding lingo
• Knows how to use the required books (especially if coding)
• Can promptly communicate any issues to the healthcare provider

The Takeaway: Medical Billers Make Office Life Easier

Daily office life should be easy, organized, and as simple as possible for every healthcare employee involved. Work itself is already hard enough so don’t make it harder on yourself as a provider by billing your patients on your own.

It’s not uncommon for healthcare providers to breathe a sigh of relief after deciding to finally hire a medical biller and coder. Unfortunately, many healthcare providers don’t consider hiring a professional biller and coder until they are extremely behind in their billing. 

By contacting a professional medical billing service, there’s no need to continue stressing about how to manage the billing and coding part of every medical office. Medical billers and coders are a profession in high demand and with very good reason.