Medical insurance billing encompasses much more than entering numbers in a pre-made form. Medical insurance billers (MIBs) must have a strong working knowledge in a variety of fields and understand the many terms they’ll encounter.
Whether MIBs choose to work in a medical facility or launch a home-based business, they’ll find it extremely difficult to find employment or clients if they’re not familiar with the terms of the trade. Nitin Chhoda discusses more.
CPT and ICD-10 codes are the method MIBs use to describe to insurance companies the diagnosis and treatment that each patient received.
Most healthcare providers only use a fraction of the thousands of available codes, but MIBs must be familiar with the lexicons used by their clients.
Billing software or electronic medical record (EMR) technology is an essential. It’s capable of handling all the coding needs and tasks MIBs will require.
Insurance coverage is available as an individual policy (purchased by individuals) group (provided by employers) and government programs (Medicare, Medicaid, CHIP, CHAMPUS VA, TRICARE and Workers’ Compensation). Each will have its own set of rules dictating what type of services and procedures are covered. Terms to know include:
- Beneficiary – who is eligible for services;
- The insured – the primary person who has the policy, making it possible for his/her dependents to receive services;
- Dependents – a spouse or children;
- Co-pays and deductibles – costs paid by patients as individuals or as a family;
- Provider – healthcare professionals, from those who treat clients to facilities that provide medical supplies;
- Exclusions – services, procedures and treatments that are not covered;
- Pre-existing condition – a medical condition that existed before the policy took effect;
- Maximums – the maximum amount an insurance company will pay within a year or lifetime;
- Pre-approval – services or treatments that must be approved by the payer prior to receiving them;
- Co-insurance – a second policy that provides medical coverage and shares the cost of an individual’s costs.
Payers and Clearinghouses
Clearinghouses use EMR software to receive reimbursement claims and forward them on to insurance companies for payment. Insurance companies (payers) have a language all their own that’s employed when dealing with practitioners and medical billing professionals. Common terms include:
- Usual fee – the cost doctors charge for specific services;
- Customary fees – are based on 90 percent of fees charged within a geographic location;
- Reasonable fees – is the lesser of what the doctor bills, usual fees, customary fees or a special fee that must be justified;
- Provider network – is a network of medical providers and facilities that beneficiaries are allowed to see that are covered under their insurance policy.
Numerous educational and certification resources are offered by professional MIB organizations to assist individuals in learning the lingo of the medical insurance billing field. Individuals can find informative books at the library, subscribing to online MIB lists and forums and asking questions, and gain experience through mentoring.
An MIB who can talk the talk with providers and payers will find multiple avenues in which to demonstrate their acumen.