Medical billers help doctors and other health care professionals get payment for services. They send bills to patients, private insurance companies, Medicare, and other insurers. Using special software, they file insurance claims electronically via an Internet connection. They keep files on patients and insurers, and use medical codes when filing claims. Most billers work from their home offices, though some work in the offices of doctors and clinics. Medical billers are sometimes known as electronic billing professionals, claims processing professionals, and medical provider consultants.
Medical Billing Service Owner Career History
Group health insurance plans first developed in the 1940s as a result of the growing expense of medical care. Since then, doctors have received much of their payment from insurance companies, rather than individual patients. With more patients using these “third-party” payers, doctors began to need assistance in dealing with the extra work of completing and submitting insurance forms. Medical billing services developed in response to this demand. Accountants, administrative assistants, and people working at home took on the bookkeeping responsibilities of doctors’ offices. When personal computers came into common use in the 1980s, medical billing changed from paper-based claims to electronic claims. Filing claims electronically required modems and specially designed software, and medical billing services were in even greater demand; doctors did not have the time to learn the complexities of submitting electronic claims. Demand for outside billing services increased even more after 1990, when the federal government ruled that doctors, and not elderly patients, were responsible for submitting claims to Medicare.
Medical Billing Service Owner Job Description
No matter how many injuries or illnesses you may have had in high school, you probably have not had much experience with insurance companies. Your parents, however, have certainly dealt with the responsibilities of maintaining insurance coverage for the family. They have saved bills, submitted claims, and dealt with doctors’ offices and insurance agencies. Health care coverage is considered an important and necessary benefit of full-time employment, so much so that many people make job decisions based on the quality of insurance available. Insurance has become a major concern as people struggle to meet the rising costs of health care.
So you can imagine the difficulties facing doctors in billing patients, filing claims, and keeping accurate patient accounts. In addition to private insurance companies, doctors receive payment from Medicare (a government insurance program for people over the age of 65, and for people with disabilities), Medicaid (a government insurance program for people of all ages within certain income limits), and workers’ compensation (insurance from employers to cover employees injured on the job). In order to get paid by these insurers, doctors must submit detailed claims. These claims include information about diagnosis and treatment, and require knowledge of medical codes.
Medical billers handle the filing of these claims. They work out of their homes or offices, and take on as many clients as they choose. According to Merl Coslick, the executive director of the Electronic Medical Billing Network of America, Inc., a national trade association, the majority of medical billers have three or fewer clients. Medical billing is often seen as supplementary income, and more than three clients may require a staff and much more time. Felicitas Cortez is one of these billers keeping her service small to allow her to work from her home office and spend time with her children. Her father is a physician, and part of his practice involves managing a nursing home. Cortez handles the billing for the nursing home patients. Most of the patients are on Medicare. Cortez designed a form that the doctor takes with him when visiting patients. On each patient’s form, the doctor lists what services the patient requires, along with his diagnosis. Once a month, these forms are sent to Cor-tez, who maintains records for the patients. “The record includes insurance information, such as the Medicare number, whether the patient is on public aid, and if there’s any secondary insurance,” Cortez says.
Cortez must also convert the doctor’s diagnosis to a special medical code. Medical billers use ICD codes that represent diagnoses, and CPT codes that represent treatment procedures. These codes are standard for private insurers across the country, and for Medicare. “I have a book to consult for the codes,” Cortez says, “but it can get complicated. I don’t have a medical background, and there are so many kinds of pneumonia, for example. There are about 100 codes for pneumonia, and insurers are very particular.” Once she has the codes she needs, Cortez can file a claim. A few insurers still accept claims submitted on paper, but most require electronic filing. Electronic claims have proven cheaper than paper billing, and they speed up processing by several weeks. Cortez uses a software system called Medical Office Management Systems, designed specifically for medical billing. After getting online, Cortez lists the place of service, the ICD code, the CPT code, and the cost of the visit, and electronically submits this claim to a clearinghouse. A clearinghouse is a service that routes the claims to both the primary and secondary insurers. She does this once a week, and reconciles accounts once a month. Payment goes directly from the insurer to the doctor, so Cortez must check with the doctor’s office to keep track of paid claims.
Medical billing doesn’t just involve computers. There are many phone calls to insurers and doctors to make sure that claims are paid. Cortez must also speak to family members of the nursing home patients to determine how deductibles are to be met.
Some medical billers handle only insurance claims, while others offer many services. They may also send bills to individual patients. They may deal with insurance companies for clients, following up on claims. Medical billers also have to maintain their own financial records, such as business expenses for tax purposes, and payment received from doctors.
Medical Billing Service Owner Career Requirements
Since medical billers use computers, online services, and special software, classes in computer fundamentals and computer programming are important. Communication and English courses will help you develop phone skills. Accounting, math, and business management classes will teach you how to keep accurate financial records. Although a medical background isn’t necessary, some familiarity with health issues and the health care industry will help you to understand insurance, doctors’ offices, and treatments. Take a course in health to gain this familiarity. A business club will allow you to meet local small business owners, and teach you about some of the demands of home-based business ownership.
Medical billers come from a variety of different educational and professional backgrounds. A college education will assist you in soliciting clients, and in performing the billing duties, but it is not required. Some background in medicine and health care can be helpful to you, but a degree in business management, or in English, can be equally beneficial. You can also benefit from office experience and an understanding of administrative procedures. Some community colleges offer medical claims billing classes; conferences and workshops in medical billing are also offered by Medicare, private insurers, and clearinghouses.
The billing software you choose for your business may include special training. The Electronic Medical Billing Network of America (EMBN) offers training courses in the New York/New Jersey area, and also distributes computer-based training packages nationwide. Courses include instruction in setting up a medical billing service, billing center management procedures, and claim billing procedures.
Certification or Licensing
Certification is not required, but it is available from the EMBN upon completion of its training courses. After successfully completing the EMBN training course and passing an examination, medical billing professionals can use the designation, certified electronic medical biller. Other associations, clearinghouses, and software companies also offer certification training courses. Many medical billing professionals work without any kind of certification or licensing at all, but certification can help you in promoting your business to clients.
Medical billers need the patience for filling out long, detailed forms, transforming treatments and diagnoses to codes, and maintaining client records. You should be organized, and have an understanding of spreadsheet programs, word processing programs, and online services. Obviously, a head for figures is important, but people skills are also very valuable. Felicitas Cortez must deal sensitively with the nursing home patients and their families in discussing payments and insurance deduct-ibles, but must be firm and persistent when dealing with insurance companies. “You have to speak to a lot of different people in different ways to get what you need,” she says. You also have to keep up on laws affecting insurers, doctors, and billing methods.
Exploring Medical Billing Service Owner Career
There are many volunteer opportunities in the health care industry available to high school students. Assisting at a hospital or nursing home will give you some background in medical terminology and a doctor’s routine. Working part-time for a pharmacist can give you similar experience, and may include working with Medicare and Medicaid forms, and preparing medications for nursing homes. Many school clubs elect treasurers who handle receipts, payments, and bills; either volunteer for the position, or assist the adviser in charge of money matters. A part-time administrative position with a local insurance agency, or any area business, can give you valuable experience in handling calls, preparing forms, and completing billing procedures.
From chiropractors to psychiatrists, health care professionals must deal with insurers, billing patients, and keeping accurate payment records. Anybody who needs to file claims with third-party payers, including personal trainers and physical therapists, can benefit from the services of a medical billing professional. Medical billing service owners may work with one specific area of health care, or they may have a diverse clientele. Their clients may be in their local area, or they may work with clients in other cities, contacting them by phone, fax, and email.
Try to get some experience with medical billing before investing in the business. Working in a doctor’s office can quickly familiarize you with the job’s requirements, and will give you experience that you can promote to potential clients. Be very sure that the business is for you, because start-up costs can run into thousands of dollars for computer and printer, database and marketing software, and medical billing software. Be very careful about what billing software you select; there are many different programs available. The cost of software ranges from $100 to $12,000. In general, the software used by active billers around the country costs between $500 and $1,000. The lower-cost programs may offer all you need for a small business. However, more expensive programs may also include additional services, such as access to a clearinghouse that routes your electronic claims to primary and secondary insurers.
Make sure you can take on enough clients to support your business. Most general care physicians have their own billing staffs. You will have to convince these doctors that they will benefit from contracting an outside billing service, and that you have the skills to handle the billing and improve payment methods. By joining a professional association, you can receive guidance and support from other medical billers.
The majority of people with their own billing services prefer to keep their businesses small, handling only a few clients. But it is possible to expand your business into a service for several doctors. According to Merl Coslick of the EMBN, there are about 600 companies grossing over $1 million a year and processing tens of thousands of claims a week. Obviously, it takes a much greater investment to expand— medical billing service owners will need a staff, additional office equipment, and commercial office space.
Service owners can still advance into other areas while maintaining a small operation. Some experienced billing professionals serve as consultants for doctors’ offices. They train an office’s internal billing staff, help build billing records, and oversee the electronic claims filing.
Some medical billers charge their clients for each claim processed; others charge a percentage of the insurance payment. Some billers have contracts with doctors and charge flat weekly or monthly fees. No salary surveys have yet been conducted on independent billing service owners, but Coslick estimates that a service processing 300 claims per month can make $10,000 per year for each client. Though most owners of medical billing services choose to operate only part-time, those working full-time may be able to process 1,500 claims or more per month.
Most medical billers work in the comfort of their own home offices. Although they don’t have any direct supervision, clients regularly contact them to check on the status of an insurance payment. They spend much of their time on the phone and on the computer. In some cases, billers may visit a client’s office to collect forms; some billers, however, simply use fax machines and messenger services to exchange information. Billers who offer consulting services spend some time in doctors’ offices working closely with billing staff members. The hours per week will depend on the number of clients. Serving only a few clients requires approximately 20 hours a week; any more than three clients requires 40 hours or more a week. It is not necessary to keep regular business hours, since so much work is done at the computer using electronic systems. Medical billers can set their own schedules, working evenings and weekends if they prefer.
Medical Billing Service Owner Career Outlook
Although many Americans are still without health insurance, some government programs are actively involved in providing insurance to the elderly, children, people with disabilities, and those with low incomes. The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, Medicaid, and the State Children’s Health Insurance Program provides health insurance for approximately 87.4 million Americans. This number will increase as the baby boomer generation grows older, and as the newly formed Children’s Health Insurance Program evolves. A CMS study projected health care expenditures to reach $4 trillion by 2015. This will mean the filing of billions of insurance claims. Doctors will require even more assistance in billing, and receiving payments, particularly as more billing procedures are done electronically. Merl Coslick believes that more billing professionals will become consultants to doctors’ offices. Within three to five years, he predicts, the bulk of billing will be done internally, and consultants will be needed to train staff in medical billing software.