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A Day in the Life of a Medical Claims Biller

Before you start a medical claim billing service, find out the essential tasks you'll be responsible for.
A Day in the Life of a Medical Claims Biller
Image credit: Tom Grill | Getty Images

The following excerpt is from Start Your Own Medical Claims Billing Service. Buy it now from Amazon | Barnes & Noble | iTunes

Let’s take a look at what a medical insurance biller’s (MIB’s) work life is like, what sort of tasks you can expect to perform on a daily basis and how they’re completed.

One of the great joys of running a medical billing service is that you can arrange your workload around any schedule you choose. Some MIBs are early birds; others find they get more accomplished in the afternoon or at night.

What, specifically, you’ll be doing during your peak hours and beyond will depend on how you’ve structured your services. Some MIBs perform full practice management for their clients -- they handle all aspects of the doctor’s accounting from submitting electronic claims to billing patients to tracking accounts payable and receivable. Other medical billers prefer to deal only with insurance claims submissions. Most MIBs, being savvy businesspeople, take on whatever is required to land the client and therefore find themselves working in different ranges of practice management for different clients.

Your most basic task will be generating and transmitting insurance claims. Software makes this part a snap. Although each program has its own variations, the basic setup is the same, featuring a screen or screens where you enter the patient’s particulars, including name, phone, address, policy number, date of injury or illness, the diagnosis and procedure codes and the doctor’s charges.

When you first take on a practice, you’ll spend a fair number of hours entering all the doctor’s patients into your program. Although this is time-consuming, it’s well worth the effort -- afterward you’ll always have most of the information you’ll need on file. Unless established patients move or change employers or insurance companies, all you’ll need to fill in are the details of the illness or injury, the diagnosis and procedure codes and the charges. The basics -- name, address, phone, employer, policy number(s), insured family member’s name and relationship, your own file or ID number for the patient -- are already entered.

You’ll find the procedure and diagnosis codes, otherwise known as the CPT (for Current Procedural Terminology) and ICD-10 (for International Classification of Diseases, 10th revision and most properly called ICD-10-CM, for Clinical Modification) codes, on the superbill.  

Proper procedure codes are one of the most important parts of any insurance claim -- they tell the carrier exactly what services or procedures were performed and/or what supplies were provided. Procedure coding can be extremely complex and requires a considerable knowledge of medical terminology, operative procedures and other aspects of clinical medicine. The more you know about coding, the more help you can be to your doctors -- and to yourself.

In the groove

The CPT codes are revised every year, which means you need to stay up-to-date. When you take on a new client, you should grade his or her current superbill. Does it contain the latest ICD-10 codes specific to that practice? If not, recommend changes. You’re asking for trouble if you use outdated codes. The chances are great that the carrier won’t pay the same on an old code; in fact, it may refuse to recognize it. Either way, reimbursement won’t be swift, and you won’t look good.

If a claim is denied because of the diagnosis code, it’s usually for one of the following reasons:

  • No diagnosis is provided.
  • The diagnosis given is inconsistent with the service or procedure provided.
  • The diagnosis doesn’t substantiate the need or level of service provided.
  • Multiple diagnoses are given, which confuses the claims examiner.

The first two problems are easy to solve. Make sure you have at least one diagnosis for each procedure or group of related procedures, and be sure the diagnosis is consistent with the procedure listed.

Moving on to Problem Number 3: If the diagnosis doesn’t validate the level of service, then the doctor has probably failed to code for extenuating circumstances. Let’s say, for example, that Dr. Whosit billed a two-hour procedure at a three-hour rate. To get Dr. Whosit paid, you’ll need to send an explanation with the charge, making it clear that the procedure took extra time because the patient’s diabetes complicated the surgery, for instance.

Problem Number 4 can also be solved with some vigilance on your part. Many doctors have a tendency to over-diagnose for the purposes of insurance billing, using two, three or even four different ICD-10 codes to justify a single procedure. In this case, more is not better. All this does is create confusion in the mind of the claims examiner, who will then try to decide which, if any, of the multiple codes submitted justify the procedure -- and its payment. Often such claims are either sent back to the doctor for additional information or forwarded to a nurse or physician reviewer.

Just the fax, Ma’am

Now that you know all about coding, let’s backtrack a bit. How are you going to get the superbills or day sheets to take your CPT and ICD-10 codes from?

Most MIBs rely on one or a combination of four methods: the fax machine, email, personal pickup and delivery and the USPS. Emailing and faxing are generally viewed as the best ways to go: Information can be sent quickly without worrying about weighing, stamping or delivery time. Whatever methods you choose, the materials you’ll be working with will fall into these basic categories:

  • New patient information sheets and information sheets detailing changes to estab­lished patients’ files
  • Superbills or day sheets with CPT and ICD-10 codes written in or checked off
  • EOBs for previously submitted claims
  • Mail from insurance carriers and from patients regarding previously submitted claims or changes in policies or patient information

Ideally, all these materials will be presorted for you in chronological order and batched by type of material. You may want to train your clients to present them to you this way, or you may prefer to save them the hassle and sort through it yourself.

You should take the time to give everything the once-over and make sure you have the information you need. Look, for example, at the superbills or day sheets. Are codes entered or checked? Is the necessary patient information entered and legible? Is it clear whom mail is from or about? Giving all this a glance can save you time -- you can collect missing information as soon as possible.

Working with claims

Your software miraculously produces your claims, ready for online delivery, but to where? The clearinghouse rounds up all your claims and routes them to the proper insurance carriers. It also reconfigures your data into whatever format each carrier requires. Even better, the clearinghouse automatically audits each claim, checking it for clerical errors and omissions before sending it on to the carrier. When it finds a goof, it redirects the claim back to you so you can correct the problem.  

You may, however, choose not to use a clearinghouse for all your claims. In most areas it’s just as easy -- and less expensive -- to submit directly to Medicare and Blue Cross as it is to send claims through the clearinghouse.

After you’ve entered the day’s claims, it’s time to submit them. If you’re working with paper claims, you print them out -- one copy for your files and one for the insurer -- and set your copy aside. Then it’s just a matter of fold, lick and stamp.

If you’re working with electronic claims, you’ll go to the online portion of your software and send the day’s batch speeding to your clearinghouse or carrier. Some clearinghouses will drop the claims to paper for you, meaning you send the claim online and the clearinghouse prints a paper copy and sends it on its merry way.

The clearinghouse quickly reviews your claims, forwards the clean copies to the respective carriers and alerts you to the rejected ones -- if any -- via a report called the Audit/Error Report or Sender Log. At this point you can and should print the report for your records. You can also make corrections to the rejects and resubmit. In the case of rejects (such as incorrect codes) that need doctor clarification, call the client immediately or set the claim aside to be dealt with later.

Getting paid

If you haven’t received payment on a claim within 45 days after submission, it’s time to find out what the problem is. Some carriers require written inquiries; some Medicare and Medicaid carriers require specific inquiry forms; some carriers allow telephone inquiries. In any case, you should copy all written inquiries and annotate them to the patient file. For telephone questions, be sure to get the name and phone extension of the person you speak with and note these details on your file along with the date and particulars of the conversation. If it’s apparent the payer has made an error on a claim, don’t hesitate to challenge the payment amount. Medicare and other insurers will correct mistakes if you bring them to their attention. Even if you made the error, it’s always possible to resubmit a claim.

When you discover an error on a claim that’s resulted in insufficient reimbursement, submit a corrected claim. Clearly mark the claim: Corrected Billing -- Not a Duplicate Claim. Add a note specifying the error and, if necessary, additional documentation to support your correction.

When you receive a patient’s EOB (explanation of benefits), start grading the insurer’s work. Compare the charge amount listed with the charge amount in your patient’s account ledger.

Check your client’s codes against those on the EOB for errors or changes that the carrier might have made. Sometimes payers will down-code a procedure from the actual one to a less costly one -- inadvertently or intentionally -- and pay based on the substituted code. In some cases, the payer’s data entry department may simply have transposed two digits in a CPT code, resulting in a different procedure from the one performed. In other cases, your client might have used an outdated CPT code that the insurer did not -- or refused to -- recognize. Here the insurer may review the claim and pop in the valid code for you or deny the claim and leave it up to you to resubmit.

Edition: December 2016

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