A day in the life of a medical biller

Hi. I'm Heather, and welcome to the second lesson in the intro to medical billing course. If you're here, you're ready to hear about what exactly a medical biller does and what their day to day looks like. I'm gonna break down some key concepts, like claims and reimbursement, walk through a typical day in the life of a medical biller, and give you real examples of the daily tasks you'll handle in this role. Get comfy because we've got a lot to cover.

Alright. Let's start with the basics. What is a claim? In health care, a claim is simply a request for payment that gets sent to an insurance company after a patient has received medical care.

It's like the bill that gets sent to the insurance to cover services, like doctor's visits, surgeries, or tests. Here's a simple scenario. Let's say a patient visits their doctor for a routine checkup. After the visit, a claim is created that lists all the services the patient received.

This claim gets sent to the patient's insurance company, which reviews it and decides how much they will pay the doctor based on the patient's coverage.

So as a medical biller, your job is to create and submit these claims, ensuring all the correct information is there so the provider can get paid. Claims are the backbone of the medical billing process.

Now let's talk about reimbursement, which is basically just a fancy word for payment.

When an insurance company receives a claim, they decide how much of the total cost they're gonna pay based on the patient's insurance plan. The payment they'll send to the health care provider is called reimbursement.

Here's a real world example.

Let's say the patient's total bill for a checkup is two hundred dollars Based on the patient's insurance, the company may decide to pay one hundred and fifty dollars and the patient might be responsible for the remaining fifty dollars As a medical biller, it's your job to track that payment and make sure the provider gets reimbursed.

But sometimes, things don't go as smoothly. A claim might get denied, which means the insurance company decides not to pay for some reason. Maybe they need more information or they think the service wasn't covered under that patient's plan. When that happens, it's the biller's responsibility to follow-up, fix any errors, and resubmit the claim. It's a lot of problem solving, and your attention to detail makes all the difference.

Now let's go over some of the medical biller's main daily tasks.

First, you'll create and submit claims.

As I mentioned earlier, your job is to take all the information from a patient's visit and turn it into a clean, accurate claim. This involves entering codes for service, accurate claim.

This involves entering codes for service, double checking that everything matches the patient's insurance details, and making sure no information is missing.

For example, if a patient had a procedure done, you'd enter the codes that correspond to that procedure, like a doctor's office visit or a blood test. You'd then submit that claim to the insurance company for payment.

Next, there's following up on denied claims.

Not every claim goes through the first time, and part of your job will be to appeal claims that get rejected.

You might need to contact the insurance company, correct any mistakes, or gather additional information from the patient's medical record.

Then there's posting payments.

Once the insurance company sends reimbursement, you'll enter that payment into the system, making sure everything matches up correctly. If the insurance doesn't cover everything, you'll also generate bills for patients, which is where things like co pays and deductibles come in.

Let's walk through an example of how a medical biller's role goes hand in hand with a medical coders, because, really, both roles work would not be complete without the other.

The coders' job is to take the details of a patient's visit, things like diagnoses and treatments, and assign them specific codes for those services.

Once a coder finishes their part, it's your turn as the medical biller to step in and handle the billing side of things.

Let's say the coder has just sent you the information for a patient who came in for a routine checkup. You'll start by logging in to the electronic health record, the EHR, which is where all the patient's medical records are stored and checking the details the code are entered. Here's what that might look like. You'll see things like the patient's name, the date of their visit, and the codes that correspond to the service they received.

For example, there could be a code for the doctor's exam, maybe another for a lab test, and so on. Your job is to review these codes to make sure everything looks accurate. You want to make sure the services are correctly coded and that there are no missing details. It's important that everything matches what exactly happened during the visit. Once you've reviewed the info from the EHR, you're ready to create a claim. This is what you'll send to the patient's insurance company to request payment for the services provided.

Here's what a claim might look like. Information such as the patient's details, the codes for the services they received, and their insurance information are dropped to a claim. For instance, if the patient came in for a routine exam and a blood test, codes for both would be listed.

The total cost of services is also included on the claim. This is the amount you're asking the insurance company to pay. This step is critical because if any of this information is incorrect, it could delay payment or result in the claim being denied.

After double checking everything, it's time to submit the claim electronically to the insurance company. Most billing systems will let you do this with a click of a button.

Once it's submitted, the insurance company will review it and decide how much they'll pay. But that's not the end of your work. You'll need to keep an eye out on the status of the claim to make sure it's being processed. And if it's denied or rejected, you'll work to resolve any issues.

Remember, submitting the claim is just one step. You'll also be responsible for following up to ensure the provider gets paid correctly and on time. It's all about keeping things moving and making sure no details get left behind.

So that's a quick look at what happens after you get the info from the coder. You're the one making sure all the pieces fit together, reviewing the codes, creating the claim, and submitting it to the insurance company for payment.

So what can a typical day look like for you as a medical biller?

Picture this. You start your day by reviewing the previous days and countercharges.

Your job is to make sure all the services provided are accurately captured, then you start submitting claims.

Midmorning, you might check the status of any pending claims and follow-up on any denials. You'll make phone calls, send emails, or resubmit claims with updated information.

Every now and then, you might hit a tricky denial, so you'll work with the insurance company to figure out the problem and get it resolved.

By the afternoon, you're likely posting payments from insurance companies, recording them in the system, and making sure everything matches up on the claims you submitted.

At the end of the day, you might be generating bills for patients who owe co pays or have balances left after insurance.

While a lot of your job is working independently, you'll also interact with different parts of the health care system.

In addition to regularly interacting with medical coders, you'll also communicate with insurance companies a lot, whether it's to submit claims, follow-up on denials, or resolve any payment issues. You might spend part of your day on the phone or sending emails to insurance representatives.

As for who you report to, it depends on the size of the health care organization.

In a smaller clinic, you might report directly to the office manager or even the doctor. In larger hospitals or health care systems, you likely report to a billing manager or a revenue cycle director who oversees the entire billing department.

Alright. Let's talk about something that's really important for medical billers, compliance.

Now if you're brand new to the field, compliance might sound like a confusing industry term. But at its core, compliance just means following the rules. In medical billing, there are lots of rules, especially when it comes to protecting patient information and billing accurately.

Why? Well, health care deals with very sensitive information, people's medical histories, personal data, and how they pay for their care. So there are laws in place to make sure that information is handled correctly and that the billing is fair and accurate.

One of the biggest laws you'll need to know is HIPAA, which stands for the Health Insurance Portability and Accountability Act. I know. It's a bit of a mouthful, but what's important to know is that HIPAA protects patient privacy. As a medical biller, you'll be handling patient records and payment information, and you need to make sure that data stays secure.

For example, if you're working with electronic health records, you need to make sure the system is secure and that only authorized people have access. And if you're emailing patient information or insurance details, it's important to use secure encrypted channels.

Now compliance isn't just about privacy. It's also about making sure the bills you submit to insurance companies are accurate and honest. There are rules about how services should be billed, and these are based on the coding and insurance regulations you'll learn in your medical billing training.

For instance, you need to make sure that you're billing for services that were actually provided and that the codes you're using match those services. If the coding is wrong or inflated, meaning it suggests more care was given than actually was, that can lead to something called fraud, which is a big problem in health care billing. It's your responsibility to double check the codes and ensure everything lines up. This keeps you, the health care provider, and the patient on the right side of the law.

Here's another thing to keep in mind. Rules change. Health care billing is always evolving, and that means you need to stay up to date with new laws, coding updates, and insurance requirements.

For example, there are regular updates to billing codes, like new codes being introduced or old ones being changed.

This happens because health care changes as new treatments and technologies come out, and insurance companies update their policies to reflect that. So it's part of your job to stay on top of those changes.

A great way to stay compliant is by continuing education.

Many employers will require you to take periodic training to keep your skills and knowledge current, and you'll likely be renewing your certification over time to ensure you're in the know. So staying compliant is all about making sure you're following the rules, protecting patient privacy, billing accurately, and keeping up with changes in the industry. And remember, staying compliant doesn't just protect your job. It ensures the health care system runs smoothly for everyone involved.

Well, that's a look in the daily life of a medical biller. Watch the next video lesson of this course to explore what skills every medical biller needs and what education and experience requirements to expect for this role.