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Medical billing is the process of translating healthcare services into billing claims and submitting them to insurance companies for reimbursement. It ensures healthcare providers receive timely and accurate payments for their services.
A medical biller is responsible for verifying patient insurance, coding services, submitting claims, following up on unpaid claims, posting payments, and resolving billing or insurance issues.
Medical coding involves assigning standardized codes (ICD-10, CPT, HCPCS) to diagnoses and procedures, while medical billing focuses on using those codes to generate claims and manage the payment process.
The primary coding systems used are ICD-10 for diagnoses, CPT for procedures, and HCPCS for medical supplies and non-physician services.
Patient responsibility includes costs not covered by insurance, such as deductibles, copayments, coinsurance, and non-covered services
HIPAA (Health Insurance Portability and Accountability Act) ensures patient data privacy and security. Medical billers must comply with HIPAA to protect sensitive health information.
Prior authorization is approval from an insurance company before certain procedures or services are provided to ensure they will be covered.
An insurance claim is a formal request submitted to an insurance company for payment of healthcare services provided to a patient.
A claim denial occurs when an insurance company refuses to pay a claim due to errors such as incorrect coding, missing information, lack of authorization, or coverage issues.
Medical billers review the denial reason, correct any errors, submit an appeal if needed, and follow up with the insurance company to ensure proper reimbursement.
An Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA) provide details on how a claim was processed, including payments made, adjustments, and patient responsibility.
Common errors include incorrect patient information, coding mistakes, missing documentation, duplicate claims, and late claim submissions.
Key skills include attention to detail, knowledge of medical codes, insurance regulations, analytical skills, communication abilities, and proficiency in billing software.
Accuracy prevents claim denials, reduces payment delays, ensures compliance, and improves revenue cycle efficiency for healthcare providers.
Excellence in healthcare begins with dedication, compassion, and a commitment to continuous improvement.