Medicine is an art, it is science and business. There are scientific and artistic aspects those doctors learn in the profession of medicine. Doctors have to be paid which requires a different skill that is complex and comes with administrative professional. Hint a Medical Biller and Coding. Medical Billers and Coders work with clinics, doctors, hospitals, patients, and other medical facilities. Submitting claims to insurance companies help ensure that supporting staff and doctors are properly reimbursed for services rendered. When one is a Medical Biller there are abbreviations and acronyms that help save time when filing a claim. Many offices have their own most frequently used acronyms and abbreviations that they use to do their coding and billing. There are many acronyms and abbreviations used in all medical practices. Here are some examples:
EDI (Electronic Data Interchange): Electronic claims that are sent to a central clearinghouse for distribution for individual carriers.
EOB (Explanation of Benefits): This refers to a document that is issued by an insurance company that responds to a claim statement which outlines what services are covered and what services are not, and what level of reimbursement are available.
HIPAA (Health Insurance Portability and Accountability Act): The privacy rule, which outlines certain entities in a person health plan, clearinghouses can disclose or use person health information, and who may be allowed to access a patients personal medical records.
HMO (Health Maintenance Organization): Is a health management plan that requires patients to have a PCP (primary care physician). A PCP is where patients seek out most of their initial treatment at. If the PCP feels like it is necessary to seek treatment from specialist they will send a patient to within that network. CMS (Centers for Medicaid & Medicare Services): United States Department of Health & Human Services that administer Medicaid, Children’s Health Insurance Program, and Medicare.
PPO (Preferred Provider Organization): This allows patients to visit providers that are contracted with their insurance companies. If that patient visits a non-contracted provider, the claim will be considered out-of-network.
WC (Workers Compensation): The U.S. Department of Labor program provides insurance for employees whom may get injured on their place of employment.
POS (Point of Service): An insurance plan that offers low cost HMOs when a patient sees network providers by their insurance company. Currently the medical coding is transitioning from ICD-9 to ICD-10. ICD-10 is presenting itself with more specific information and data, which in the turn helps with the World Health Organization (WHO). With the new ICD-10 codes have increased in character length giving the biller to right which specific extremity it is on a patient (left arm, right arm). ICD-10 compliance date is coming October 1, 2014. ICD- 10 reimbursement has said to have some challenges with DRG payments. The changes that are known to take place do not affect the DRG (Drug Related Groups) calculation as expected. The majority of reimbursements that come to a hospital are based on DRG.
The impact on an organization with Medicare revenue of $150 million using a -0.04% variance it would be a $600,000 loss, which is still a substantial amount. Amounts of reimbursements can shift and vary depending on mix of a facilities DRG’s. In ICD-10 financial impact will be with slowdown in submission of final codes, rejections and denials because on inaccurate codes, and productivity loss (Smith, 2013). Medical billers and coders should not be overly concerned with these changes.
Medical Billing and Coding specialist deal with patients medical records which contain physician’s notes for services that were rendered at the time
of the patients visit. The medical biller and coder translates that information to a five-digit code from American Medical Association Current Procedural Terminology (CPT) or from Statistical Classification of Disease and Related Health Problems (ICD). It is crucial for the ICD and CPT codes match with the services rendered or a claim will be rejected, many claims are initially rejected.
The cost of healthcare is on the rise and the demand for services has increased of required and specialty services feed into the financial greed among HMOs. The major bulk of hospital bills are paid directly by the patient’s health insurance provider which are termed the payer. 68% of the United States population has private insurance which is provided by their employer or self-pay. Around 9% of the population are self-payers who direct-purchase their insurance. There are two main categories of third- party payers they are government and private.
Medicaid and Medicare are the largest government issued payers. Reimbursements for both private and governmental have policies that support therapeutics, diagnostics and new medical medicines and technologies. It is clinically evidence based approvals such as diagnostic test, prescription medicines, clinical trials and however insurers are using to help with their life cycle. With reimbursements there are incentives for medical facilities and doctors. Reimbursements are a source of revenue for hospitals; payers do not pay a full price for services. Healthcare has become the economy’s largest force.
Healthcare services are very different from other industries because of the production rate. In the healthcare industry the technology advancement makes a bigger impact than other industries. An assembly line at a manufacturing plant process thousands of the same or identical items. These items are produced by robots and machines which dehumanizes the industry. Patients are cared for on unique terms one by one. Health care is also locally based in every city and state and are not outsourced or out of the country. As the healthcare industry is growing the productivity is slowing down. Thus the cost of production in the healthcare industry steadily rises.
(n.d.) AMA American Medical Association. “The Difference between ICD-9 and ICD-10”. Retrieved July 13, 2013 from
Marcinko, D. (2011). Recognizing the Differences between Healthcare and Other Industries. Retrieved July 20, 2013 from
http://medicalexecutivepost.com/2011/01/19/recognizing-the-differences-between-healthcare-and-other-industries/ Smith, Donna. (2013). “Reimbursement Impact of ICD-10: Should You Be Concerned?”. Retrieved from \ August 15, 2013 From
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