Essential Skills and Responsibilities of a Professional Medical Biller: A Comprehensive Guide

1. What are the medical billing software’s you used ? The most popular medical billing software’s are.

If you are novice medical biller, mention that you are quick learner and can learn any new software or application.

2. Explain the process of medical billing ?

Patient Registration: When a patient arrives at a healthcare facility, they are asked to provide their personal and insurance information. This information is used to create a patient record, which includes demographic information, insurance coverage, and billing information.

Insurance Verification: Once the patient’s insurance information is obtained, the healthcare facility will verify the patient’s insurance coverage and benefits. This step is important to ensure that the services provided are covered by the patient’s insurance plan.

Treatment and Documentation: Once the patient has received medical treatment, the healthcare provider or facility will document the services provided, including the diagnosis, treatment codes, and any other relevant information.

Claim Creation: After the documentation is complete, the healthcare provider or facility will create a claim form using the appropriate billing codes. This claim form will include the services provided, the cost of those services, and any insurance information.

Claim Submission : The claim form is then submitted to the patient’s insurance company for payment. This can be done electronically or by mail, depending on the insurance company’s requirements.

Claim Adjudication : The insurance company will review the claim to ensure that the services provided were covered under the patient’s insurance plan. The insurance company will then determine the amount of payment that will be made to the healthcare provider or facility.

Payment and Billing : Once the claim is approved, the insurance company will send payment to the healthcare provider or facility. Any remaining balance will be billed to the patient.

Follow up : If the claim is denied or payment is not received, the healthcare provider or facility will follow up with the insurance company to determine the reason for the denial or non-payment and take appropriate action.

3. What are the common challenges in medical billing ?

4. Do you hold any certifications in Medical Billing?

Yes, CPMB-Certified Professional Medical Biller

5. Most common medical billing errors ?

Incorrect Patient Information: One of the most common errors in medical billing is incorrect patient information, such as a misspelled name, incorrect date of birth, or incorrect insurance information. This can result in claims being rejected or delayed.

Coding Errors : Coding errors occur when the wrong procedure or diagnosis code is used on a claim form. This can lead to a claim being rejected or denied by the insurance company.

Duplicate Billing : Duplicate billing occurs when a claim is submitted more than once for the same service. This can result in overpayment by the insurance company and may lead to audits and fines.

Upcoding or Downcoding : Upcoding occurs when a provider submits a claim with a higher-level service code than was actually performed, in order to receive a higher payment. Downcoding occurs when a provider submits a claim with a lower-level service code than was actually performed, in order to avoid a possible rejection or denial by the insurance company.

Non-Covered Services : Non-covered services occur when a provider submits a claim for a service that is not covered by the patient’s insurance plan. This can result in the patient being responsible for the full cost of the service.

Missing Information : Missing information occurs when a claim form is incomplete or missing required information, such as the provider’s signature or the patient’s consent. This can lead to delays in payment or a claim being rejected.

Incorrect Modifier Use : A modifier is a code used to provide additional information about a service or procedure. Incorrect use of modifiers can result in claims being rejected or denied.

6. When you get rejected claims, how do you manage them

A good clearing house rejects the claims for various reasons like incorrect insurance information, timeliness, non-covered services, demographic errors etc.

Make sure that information is correct before claim submission and if rejected, fix at earliest and resubmit.

7. Common Clearing house for claim submissions ?

Availity : Availity is a healthcare information technology company that provides a variety of services, including clearinghouse services for medical claims. They support a wide range of insurance payers and offer real-time claim processing.

Change Healthcare : Change Healthcare is a healthcare technology company that offers clearinghouse services for medical claims as well as revenue cycle management, electronic health records, and other healthcare solutions.

Office Ally : Office Ally is a company that offers a suite of practice management and medical billing software, including clearinghouse services for medical claims. They offer a variety of services for small to medium-sized healthcare practices.

Emdeon : Emdeon is a healthcare information technology company that provides clearinghouse services for medical claims as well as a variety of other healthcare solutions, including revenue cycle management and analytics.

8. What is claim scrubbing ?

Claim scrubbing is a process that helps to identify and correct errors in a CMS-1500 claim form before it is submitted to an insurance payer. The process involves using software to check the claim form for errors and inconsistencies, such as incorrect patient information, invalid diagnosis codes, or missing information.

Claim scrubbing software can identify potential errors and provide suggestions for corrections, which can help to reduce the number of rejected or denied claims. The software can also identify potential coding errors, such as upcoding or downcoding, which can result in overpayment or underpayment.

9. Top 5 duties of a Medical Billers ?

10 . Essential skills of a Professional Medical Biller ?

Knowledge of Medical Terminology: A medical biller must have a good understanding of medical terminology to accurately code medical procedures and diagnoses.

Understanding of Insurance Claim Processing: A medical biller must understand the insurance claim process, including the requirements of different insurance payers and the regulations and policies that govern the process.

Attention to Detail : Medical billing requires a high level of attention to detail to ensure accuracy and completeness of the billing process.

Proficiency with Medical Billing Software : A professional medical biller must be proficient in using medical billing software to efficiently manage and submit claims.

Communication Skills : A medical biller must have strong communication skills to interact with healthcare providers, insurance companies, and patients to resolve billing issues.

Analytical Skills : A medical biller must be able to analyze complex medical bills and insurance claims to identify potential errors and discrepancies.

Knowledge of HIPAA Regulations : A professional medical biller must have knowledge of HIPAA regulations and guidelines to ensure the confidentiality and security of patient information.

Time Management Skills : Medical billing can be a high-pressure job that requires the ability to prioritize tasks, manage time effectively, and meet deadlines.

Customer Service Skills : A medical biller must have strong customer service skills to interact with patients and address their billing concerns.

Continuing Education : The medical billing field is constantly evolving, and a professional medical biller must keep up-to-date with changes in regulations, technology, and industry trends through continuing education and training.

Overall, a professional medical biller must possess a combination of technical skills, knowledge of healthcare practices and regulations, and strong interpersonal skills to be successful in this field.