Medical Billing Business — Costs You’ll Incur When Starting Part 1

Medical Billing Business — Costs You’ll Incur When Starting Part 1

One of the primary attractions of a career in the medical insurance billing (MIB) profession is the low startup costs compared to other businesses. Most MIBs plan for big expenditures, but fail to figure in small but essential costs.

In this insightful, two-part article, Nitin Chhoda examines the cost of doing business and what MIBs can expect to spend when they open their own business.

medical billingMIBs typically begin by operating their business from home to save on costs. Renting office space is a major expense that can cost thousands of dollars a month depending on the location.

To equip a medical billing business with the basics will require approximately $5,000 and there are numerous ways entrepreneurs can reduce their costs. Keep in mind that prices fluctuate among retail outlets and geographic areas.

Computer System

It can be tempting to purchase the most expensive medical billing business model available, but a good computer system that includes the hard drive and a minimum of a 19-inch monitor can be obtained for approximately $2,000. A 19-inch monitor will help prevent the eye strain of being in front of the computer for eight hours a day.

The operating system must be the latest version of Windows to be compatible with medical billing software.

A multi-function machine, often called an all-in-one, is capable of printing, scanning, copying and faxing. All of the capabilities will be required as part of the medical billing process. A basic model can be purchased for as little as $100.

Medical Billing Software/EMR

MIBs have a wealth of medical billing software from which to choose. The software represents a major outlay for a fledgling business. MIBs can expect to spend around $700 for medical insurance billing software, though there are systems that cost thousands.

Another option is EMR software that provides all the capabilities required for medical billing, communicating with clearinghouses and maintaining HIPAA compliance when dealing with patient data.

Fully functional EMR systems are available and only require a modest monthly fee. An EMR that has built in security features, is easily updated when needed, can handle the full range of ICD-10 codes, and can be used to create CPT code databases to reflect client specialties.

Clearinghouse Contracts

Medical billing businesses will be required to contract with a clearinghouse, which allows them to submit client claims for reimbursement. The average cost is $300. MIBs should be prepared for the need to purchase additional software for complete clearinghouse compatibility or to offer clients extra services, an expense that can run around $350.

Printed Material

medical billing businessManuals and reference materials for medical billing business will account for $200-$300. They encompass coding manuals, insurance directories and disease classifications, along with medical terminology and the intricacies of submitting claims.

Available in book form, many are also offered as CD-ROMS that can offer valuable savings. Part of the reference library should include books on marketing the business.

A career in the medical insurance billing field is one of the few professions that require a minimum of investment by entrepreneurs.

Computers, software, reference material and clearinghouse fees represent the major financial outlays, but there are many smaller costs of which MIBs may not be aware. In the second part of the series, Chhoda will explore the smaller, but no less important costs of launching a medical billing service.

How Will Pre-Existing Condition Coverage Change with Obamacare?

How Will Pre-Existing Condition Coverage Change with Obamacare?

The Affordable Health Care Act, known as Obamacare, has created a wealth of new mandates, many of which will be beneficial to policy holders. One of the new rules stipulates that no insurance company can refuse to provide coverage if the individual has a pre-existing medical condition.

ObamacareIn the past, insurance carriers could refuse to provide coverage, cancel policies at their discretion, and charge policyholders virtually any amount for their coverage.

Obamacare guarantees that all individuals are eligible for healthcare coverage and can’t be discriminated against, regardless of their health status.

A chronic health problem is no longer a reason for not having coverage.

Relief For Parents

It’s a definite boon for parents of children with a heath condition ranging from autism, blindness and cerebral palsy to asthma, diabetes, cancer and sleep apnea. Children can remain on parental policies until they turn 26, a distinct benefit for those with health issues.

The one exception for pre-existing conditions under Obamacare concerns individuals who have been purchasing private insurance. The good news is that individuals can give up their private insurance policies and purchase coverage through the health insurance Marketplace.

The mandate is also beneficial for adults. The Department of Health and Human Services estimates that 129 million people have something in their medical history that could be construed as a pre-existing condition.

Those participating in the Marketplace can choose from a bronze, silver, gold or platinum policy with varying degrees of financial outlays, all of which will cover pre-existing conditions.

Before Obamacare, insurance companies often imposed caps on the annual and lifetime amounts a policy holder could receive. Obamacare removes those caps. The downside is that the provision has already led to increases in premiums, co-pays and deductibles across the board.

There are no restrictions on the amounts insurance carriers can charge.

Open enrollment in the Marketplace begins Oct. 1, 2013 and coverage for these policies begins Jan. 1, 2014. Enrollment ends on March 31, 2014 and doesn’t open again until Oct. 1, 2014. Many will be eligible for a subsidy from the federal government to help pay for insurance and a tax credit on their income tax return.

Eligibility is determined according to income using a sliding scale.


Medicaid Instead Of The Marketplace

For individuals with an income below a specified level, Medicaid is available.

Obamacare increases the eligibility threshold, providing full coverage for the very poor.

However, many states have refused to participate in the expansion and the Supreme Court has ruled that they may do so without penalties. Participating states will offer better coverage and relaxed eligibility requirements.

Adults and children with a pre-existing condition will benefit from Obamacare. Insurance companies can no longer refuse them coverage or set annual and lifetime limitations on benefits.

At first glance, Obamacare would appear to be a panacea for those with chronic illnesses, but with carriers still free to charge whatever the market will tolerate, many are waiting to see exactly how much that benefit will cost them.

How to Get the Claim: The Billing Scenario

How to Get the Claim: The Billing Scenario

Building a clean claim is a concerted effort. It begins with the office staff that gathers demographic information and comes to fruition when the funds are deposited in the practice’s account.

Much can happen to a claim on its way to becoming a payment and in this informative article, Nitin Chhoda provides unique insights into the pitfalls that face even perfectly prepared claims and elements that affect payment.

claimWhere’s the Claim?

Aside from coding errors, reimbursement claims can go awry in many ways. The insurance provider may not be known at the clearinghouse or the clearinghouse software may glitch and submit the claim to the wrong provider.

In some instances, the payer may not be using electronic medical record (EMR) software necessitating submission of a paper claim.


Practices that utilize EMR technology receive a report in real time when a claim has been submitted. These receipts provide billers with critical information in the event of a problem. Occasionally, a claim will appear to vanish into the ether.

Clearinghouse reports tell billers when the claim was received, its status and if any problems were identified. If payment isn’t received in a reasonable time or it doesn’t appear on the biller’s daily verification, that data be used to track down the claim and rectify any problems.

Reimbursement Amounts

The whole point of submitting claim is to get paid, but the amount charged can conflict with what the payer is willing to reimburse. When differences occur, billers can easily refer to the contract the clinician has with the payer to define the reimbursable amount.

CPT codes are assigned a relative value that determines reimbursement amounts, derived from the Resource Based Relative Value Scale (RBRVS).  The value assigned is based on the work required, the cost of maintaining a practice and the malpractice/liability for which the practitioner is responsible. A formula is then employed that takes into account geographical locations to calculate the reimbursement rate.


Some contracts are RBRVS based, some aren’t, and the differences in each can be immense. Depending on how the contract is written, procedures may be paid based on RBRVS standards or discounts applied for secondary procedures done at the same time.

Some may be paid at a higher rate determined by prioritization, while others are billed according to expected payment. If the contact doesn’t state which procedure is prioritized, it’s up to the biller.

The Deciding Vote

claim submission

The ultimate decision lies in the hands of the company that provides the patient’s healthcare insurance. Once the clearinghouse completes its search for errors, it forwards the claim to the payer.

When reimbursements are less than expected, billers must refer to contract terms to obtain the maximum payment allowed.

Many hazards await claims, from submission to the wrong payer to glitches in clearinghouse software. EMRs facilitate the process by submitting claims in real time and documenting receipts from the clearinghouse.

Medical billing specialists can help clinicians boost revenues by carefully monitoring claims and referring often to contract details. Practitioners must negotiate their contracts carefully to ensure their services are adequately reimbursed.

Obamacare – The Problem it is Trying to Solve

Obamacare – The Problem it is Trying to Solve

The goal of the Patient Protection and Affordable Health Care Act was fourfold: to increase access to healthcare, reduce healthcare costs, institute more consumer benefits and protections, and improve efficiency. As different portions of the Act go into effect, it will have a major impact on virtually every individual in the U.S.

ObamacareThe Act has both a human and financial component.

According to the Center for Disease Control (CDC) more than 45 million people had no type of health insurance in 2012.

Individuals at the lower end of the financial spectrum were the most likely to lack coverage.

The Congressional Budget Office estimates the Act will reduce the number of uninsured by 27 million between now and 2023, but will still leave approximately 26 million Americans uninsured and financially unable to purchase coverage.

Increasing Access to Healthcare

Obamacare establishes healthcare exchanges and provides subsidies for low income individuals to help them purchase coverage. Millions of Americans can stop living in fear of becoming ill.

They will no longer be turned down for a preexisting condition and children can remain on parental policies through the age of 26.

The downside is an influx of new patients to practices that are already working to capacity. A poll for the Physicians Foundation showed that 40 percent of medical professionals intend to sell their practice or retire early due to Obamacare, resulting in a shortage of available clinicians and longer wait times to obtain an appointment.

Reducing The Cost of Healthcare

One of the tenants of Obamacare was the control and reduction of skyrocketing healthcare costs. The Act reduces the amounts paid by Medicare to practitioners, but allows hospitals to collect more for the same services.

The inequity is prompting many clinicians to stop accepting Medicare patients, further limiting access to care.

Clinicians are under pressure to reduce the number of tests they order and utilize the least expensive modes of treatment whenever possible. Many healthcare professionals fear the drastic reductions in reimbursements will drive potential physicians into other fields.

Healthcare costs also come in the form of copays, premiums and deductibles. Patients are already seeing an increase in all three, as insurance companies raise prices in response to the services the Act forces them to reimburse for.

With insurance companies placing limitations on reimbursements, pharmaceutical firms are reducing or eliminating medications as unprofitable to produce.

The cost of Obamacare comes in other guises. In 2018, a 40 percent tax will be placed on healthcare plans, dependent upon their value, and collected through tax returns. Fines will be assessed on individuals without insurance.

Employers with more than 50 workers must offer insurance or face financial penalties for each person they employ.

Benefits and Protections

Obamacare provides patients with some perks along with coverage. Insurance companies can’t place an annual limit on benefits, nor can they cancel policies for frivolous reasons, but the Act limits the amount individuals can place in Flexible Spending Accounts (FSAs) and purchases that can be made with the funds.

Improving Delivery and Efficiency

The Act’s components are intended to increase the overall efficiency and delivery of healthcare services. To accomplish that goal, the Act mandated use of an electronic medical records (EMR) system.

The technology is expected to allow clinicians to treat a greater number of patients per day and eliminate paper records.

ObamacareAccountable Care Organizations (ACOs) encourage networks of providers, with financial incentives for clinicians that provide a better level of care.

The focus of healthcare would begin a transition to a system of preventatives measures rather than reacting to treat disease after it occurs.

The Act also creates a panel of individuals to determine and recommend preferred treatment options.

Obamacare has four major goals through the Affordable Healthcare Act. In an effort to solve the glaring problems in the healthcare system, it will change the way clinicians practice their profession and deliver care. Patients will have greater access to clinicians, but only time will tell if Obamacare creates a nation of healthier individuals and more efficient practitioners.


Medical Billers: The Ever Expanding Field of Medical Billing

Medical Billers: The Ever Expanding Field of Medical Billing

Medical billing specialists are in high demand and the need won’t be slowing anytime in the near future. The transition to ICD-10 codes, federally mandated electronic medical record (EMR) software systems and a flood of new patients into the marketplace have all combined to create a perfect storm for skillful, experienced and certified medical billers. In this informative article, Nitin Chhoda examines the expanding field of medical billing.

medical billersWork Environments

The biggest draws for medical billers is the ability to start their own business with low overhead, work from home, and a career that can be employed from any location.

Medical billers working from home can set their own hours and the profession doesn’t have the physical requirements demanded by other healthcare fields, making it ideal for those with disabilities and stay at home parents.

Many medical professionals are outsourcing their billing activities, but the need for certified medical billers still isn’t being met. The need for medical billers is expected to increase faster than any other occupational field. A career in billing provides individuals with a decent income in a profession that’s almost recession proof.

Billers can work from home, in clinics, insurance agencies, hospitals, nursing homes and government operated public health facilities.

Easy Education

Individuals will find numerous online educational and certification opportunities that can be completed in as little as two to three months. Many professional organizations for medical billers offer courses, certification and chances to practice what they’ve learned, along with opportunities to learn about EMR technology.

New and Aging Patients

The Affordable Health Care Act changed the playing field and opened up a wealth of new opportunities for medical billers. The legislation is providing health care for millions of potential new patients, leaving providers with less time to deal with the intricacies of “paperwork”. An aging population in need of medical care is contributing to the need for medical billers with knowledge and experience of private and government-operated insurances.

EMR Technology

The use of EMR system software has been federally mandated for any entity that works with patient medical data. EMRs provide advanced methods for meeting the HIPAA standards designated for storing, retrieving and transmitting client information. The technology is changing the way billing is handled and provides medical billers familiar with the software with a multitude of opportunities.

New Medical Codesmedical billers at work

The transition to the new ICD-10 codes has many healthcare providers worried about delays in claim reimbursement. Experience with EMRs is going to be a plus for medical billers.

Familiarity with the software will allow medical billers to transmit claims without interruption and keep the flow of cash coming into the practice.

Medical billing is a quickly expanding field that demonstrates little indication of abatement. The need is obvious, with multiple online opportunities for training and certification available. As insurance companies become more determined to avoid or delay reimbursements, skilled medical billers are essential to ensure that medical professionals obtain the payments they deserve.

Government Healthcare Programs: Learn Federal and State Run Insurances

Government Healthcare Programs: Learn Federal and State Run Insurances

There’s a great debate going on in the medical community about the financial viability of treating patients covered by government-backed healthcare insurance.Many providers have said publically that they can’t afford to see those patients and will send them elsewhere for treatment.

In this timely article, Nitin Chhoda examines why it’s imperative for clinicians to learn about state and federally operated healthcare plans.

healthcare programs Incentive Payments

The list of federal health insurance plans is impressive. It includes Medicare, Medicaid, Tricare, CHAMPUS, Workman’s Compensation and Medigap plans.

Federal healthcare programs are in operation that provides incentives for clinicians in areas where a shortage of healthcare providers has been demonstrated.

The programs provide payments to recruit and retain practitioners, and awards incentive payments to providers who are already established in those areas. Some states have their own incentive healthcare programs.

Quality healthcare is at a premium in rural areas and patients are often woefully underserved. Clients tend to be older, poorer and have more health problems than their urban counterparts. Medicare maintains supplemental reimbursement healthcare programs for practitioners and clinics in rural areas.

Federal Health Programs Advantages

Each healthcare program has its own set of advantages and federal healthcare plans provide clinicians with a significant patient pool from which to draw. There are 9.64 million patients enrolled in the Tricare program alone.

Medicare pays 80 percent of patient costs and payment for practitioners participating in the Medicare healthcare programs receive reimbursements that are 5 percent higher than non-participating clinicians. Ninety percent of clean claims are processed within 15 days and payments are made within 30 days. Providers can join the Medicare network or accept patients on a case-by-case basis.

State Healthcare Programs

A majority of states operate their own healthcare programs for women and infants, along with children up to a specific age. Plans may offer prenatal and obstetric care for women and infants, along with a myriad of services for children and teens.

Coverage typically includes well child visits, dental and vision care, vaccines, prescriptions and medical supplies, mental health and substance abuse coverage, surgery and hospitalization, and diagnostic tests.

Participating in state run healthcare programs increases a clinic’s client base and many of the services can be accomplished quickly, giving simpler physical therapy documentation process, allowing practitioners to see more patients.

healthcare programs - government

Many practices are choosing to employ nurse practitioners to see this particular demographic. Even after salaries, clinics can double the number of patients being treated and revenues.

Practitioners participating in state and federal healthcare programs increase their patient base and their overall revenues.

Providers practicing in rural areas can further stimulate income through supplemental and incentive programs. Government-operated healthcare programs serve millions of individuals throughout the nation, providing practitioners with a steady stream of revenue.