Insurance Lingo: Learning to Talk the Talk of the Medical Billing World

Insurance Lingo: Learning to Talk the Talk of the Medical Billing World

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.

insuranceMedical Terms and Codes

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 Idioms

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;
  • insurance policyCustomary 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.
Medical Billing — What Not to Expect When Entering Its World

Medical Billing — What Not to Expect When Entering Its World

Medical billing is experiencing unprecedented growth compared to other professions. A variety of misconceptions and unrealistic expectations have accompanied that development.

In this revealing article, physical therapist and electronic medical record (EMR) specialist, Nitin Chhoda, examines the misconceptions associated with a medical insurance billing business.

medical billing Home-Based Billing

As the demand for medical insurance billers (MIBs) has grown, so has the number of scams promising individuals enormous incomes with no experience needed.

Despite advertisements to be found in multiple media outlets, there is no such thing as a home-based biller.

No medical provider will allow sensitive information to leave the office for someone to toil over like medical billing homework. While there aren’t home-based billers, there are medical insurance businesses that are operated from the biller’s home.


Despite claims to the contrary, a career in medical billing requires specific skills. MIBs must demonstrate a level of competence to become certified that requires a myriad of specialized knowledge. Would-be billers can’t learn as they go and should seek appropriate educational venues.

MIBs will need a working knowledge of ICD-10 and CPT codes, anatomy, clearinghouses, and both commercial and government-funded insurance programs.

Short Hours, Big Pay

Medical billing isn’t a way to get rich quick. Don’t expect to make $40 an hour or $50,000 in the first year. Those claims are the tools used by scammers. MIBs typically make $11-$20 an hour, depending on their level of experience. Entrepreneurs should be aware that the company may not make a profit in the first year, or even the second.

Launching a new business is time consuming. Operating a business from home provides individuals with the flexibility to set their own hours, but shepherding a new business to success is time consuming. Fledgling business owners should be prepared to put in a lot of long hours. Medical billing is a year-round job.


Certified medical billing people that choose to go into business for themselves are responsible for every facet of their enterprise and they must be self-starters. There will be no supervisor watching a time clock or conferring assignments. Working at home is convenient, but it can also be distracting. MIBs will need to be organized and learn to manage their time wisely.

More than Numbersmedical billing software

MIBs do more than just type numbers in a form on a computer. They verify information, check for appropriate coding and transmit reimbursement claims.

Medical billing staff also monitors claims that have been paid and those that haven’t, along with posting payments to client accounts and providing friendly reminders for patients with balances due.

Billers shouldn’t expect to sit home alone with their computers. They have to interact with others in person and via phone.

Medical insurance billing is one of the fastest growing career opportunities available and unscrupulous individuals have taken advantage of that to sell impossible dreams and expectations. Anyone who wants to launch a medical billing firm should begin with the necessary education and be willing to put in long hours to grow a respected and reputable business.

MIB Assistant — Hiring Them Right

MIB Assistant — Hiring Them Right

A large majority of medical insurance billers (MIB) start their businesses at home and as the company grows, the MIB often discovers they require an assistant.

However, liking someone isn’t enough upon which to base a working relationship and in this insightful article, Nitin Chhoda examines the criteria billers should employ when seeking an MIB assistant.

MIB assistantThe key to hiring an MIB assistant is having someone with an eye for detail. The lucky candidate will be functioning as an extension of the biller and in many instances will represent the business to the public.

The MIB assistant will need some basic skills and if they’ve never worked in the field, they’ll need to be trained.

Background Checks

MIBs shouldn’t balk at conducting a background check on potential employees. An MIB doesn’t want to discover that their new MIB assistant has a history of white collar crime, computer theft or embezzlement. It’s better to learn as much as possible about the applicant before making a definitive hiring decision.

Prior Employment

Some type of experience in the medical field is an advantage, but not a necessity. Knowledge of computers, data entry or experience with numbers is also helpful. Even if the person has no experience, if they’re trainable and learn quickly, it’s possible to have a competent MIB assistant in just a few weeks.

Electronic medical record (EMR) technology is essential for secure transmittal of reimbursement claims. Few outside the profession will be versed in their use. Many MIBs choose to leave data entry to their MIB assistant and handle the actual submissions themselves. Either way, MIB assistant must be cognizant of HIPAA security standards and thoroughly understand them.

Skill SetsMIB assistant with EMR

Organization, honesty and integrity are critical skills for an MIB assistant. The individual will be required to communicate with clearinghouses, insurers, patients and clients.

A good command of the language, a pleasant demeanor and a courteous manner are essential, as is the ability to be assertive when needed.

An ideal MIB assistant will have initiative, be able to solve problems on his/her own, and know when to bring difficulties to the attention of the MIB.

Accuracy and the ability to communicate through written means are also essential elements. A winning candidate must be detail-oriented, able to take direction and have a personality that complements the MIB. The MIB assistant will be much more than someone who enters data.

The individual will be an extra pair of hands, but they can also become a friend and the primary backup person should the MIB be unavailable.

Acquiring an MIB assistant is a huge step and one that will have a dramatic impact on the medical billing business. The ideal assistant will ease the MIB’s workload or allow the firm to take on more work. They represent the MIB and the company, making it essential that they have the skills to do it well.

MIBs: Costs You’ll Incur When Starting Medical Billing Business Part 2

MIBs: Costs You’ll Incur When Starting Medical Billing Business Part 2

Launching a medical insurance billing enterprise has the advantage of low start-up costs. Medical insurance billers (MIBs) are aware of the major financial outlays, but there are many smaller costs that are often overlooked in the excitement of entrepreneurship. In the conclusion of this two-part series, Nitin Chhoda inventories the smaller costs of doing business.


MIBs work with computers, digital communications and electronic claim submission, but there are still occasions when paper documents are required.

CMS 1500 forms are the only official claim document accepted by Medicare carriers for reimbursements. They’re available in boxes of varying quantities, ranging in price from $35 for 500 to $150 for 5,000.

Need For Speed

High-speed Internet is essential for MIBs. Those living in highly populated areas can obtain high speed service for as little as $25, but speeds are on the low end of the high-speed scale. Expenditures for the highest speeds can top $150 per month depending upon the provider. Installation fees may also be charged.

MIBs working in rural areas aren’t as fortunate in regard to pricing options. Entrepreneurs living in a country setting may have to rely on satellite service for their Internet connection. Low end speeds can be purchased for as little as $50 per month, while power plans can range from $100-$150 per month.

Customers should also be aware that many plans have usage limits. Additional costs for MIBs may be assessed for those who exceed the ISP’s limits. Some companies simply throttle the available speeds for consumers who exceed their usage.

Talk Isn’t Cheap

A dedicated phone line is essential. MIBs will spend a significant amount of time on the phone and a speakerphone is a wise investment. It allows billers to continue to work even if they’re on hold. It’s not possible to answer the phone 24/7 and MIBs will want to invest in a phone system with the ability to record voice messages.

Depending on the provider, an additional line can cost as little as $10 for MIBs, while other companies will view it as a completely “new” phone service at a cost of up to $50. A speaker phone with answering and message capabilities will range from $50-$100. Expect to pay $150 for a cordless model.

Most phone companies offer voice messaging services for a fee of up to $10 per month for those who want more than a simple phone answering machine.

Power Plays

Lost data or a fried hard drive will quickly put MIBs out of business. Invest in an uninterrupted power supply for potential outages and a surge protector. A power surge can permanently damage a machine, as can low voltage. Power protection costs range from $20-$200.

medical insurance billers

An additional cost for the protection of costly equipment and valuable data will be a thumb drive or separate drive to back-up files and information.

A thumb drive will range from $10-$70 depending on its storage space, while a 2 terra byte drive can run up to $500. Electronic medical record (EMR) technology provides regular back-up in the cloud.

The cost of conducting business requires MIBs to plan ahead for every contingency. High-speed Internet, reliable communications and data protection are relatively inexpensive, but the cost is an essential part of the medical billing business and critical for a reliable and reputable firm.

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.