Decoding Insurance: Working in the Healthcare Sector without Treating Patients

Decoding Insurance: Working in the Healthcare Sector without Treating Patients
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More than half of the US population has been diagnosed with a chronic disease and require treatment. In addition to those individuals, upwards of 70 percent of adults and nearly all children receive an annual wellness visit to screen for abnormalities. This doesn’t begin to address emergency medicine, acute illnesses, and regular cold and flu seasons.

The amount of medical care practiced in the United States is astounding, and yet the population continues to see a rise in disease.

The healthcare field is poised to respond and stands to grow exponentially over the coming years. While that information is normally marketed towards potential practitioners and those in a position to influence public policy, an increase in providers means an increase in paperwork, and the clerical aspects of patient care are growing just as rapidly.

While medical coding and billing may not seem like a glamorous position at first, careers dealing with billing, coding, and insurance enrollment can be lucrative and very rewarding once you learn the ropes.

Revenue Cycle Positions

The revenue cycle is what allows healthcare facilities to keep their doors open and the lights on. While the practitioners are busy saving lives and treating patients, there’s a whole slew of individuals pushing paper and negotiating payments to make sure the facility is able to collect payment for services rendered.

While the term may be reserved for larger health systems that deal in higher volumes, every practice has some version of this team ensuring that the paperwork goes as planned.

Revenue cycle management technically starts at the time a patient calls to make an appointment. While we may think of receptionists and office staff as customer service employees, they are often responsible for collecting insurance information or finding out how the patient intends to pay for treatment.

Even at this level of involvement, it is essential that support staff understands how insurance works, the office’s policy for billing, and several other details related to the payment of claims.

Once the patient has been seen and treatment administered, the process is handed off to the billing and coding team.

Billing and coding is responsible for making sure the diagnoses are entered correctly and match the encounter notes, creating the medical claims, and submitting the information per the specifications of the insurance company.

Unfortunately, not every insurance company follows the same rules, and neither do the individual specialties or offices, so the form, software, or process may vary depending on the situation.

Once claims have been sent in, they are monitored for payment, denials, or no response. If the claims aren’t paid in a timely manner, someone will follow up with the insurance company to understand what happened or where the process went wrong and attempt to remedy it.

Upon payment of claims, the money will be recorded according to the negotiated fee schedule and the remaining balance (if any) passed on to the patient.

Specialized Billing and Coding

If you’re more interested in becoming an expert in one aspect of the billing process, then employment at a larger facility will better serve you.

Hospitals, urgent care centers, and other large treatment facilities will break their revenue cycle down into pieces and have a department to handle each step of the process.

Traditionally, the process is broken down by coding, billing, and denials, as well as the associated fiscal aspects such as charge capture or recoupment departments.

Coding and denials often intersect in medical and insurance billing because many payment errors can result from incorrect or misleading coding.

Within each billing and coding department, the work may be further broken down depending on the size and scope of an organization.

If you are employed by a specialist’s office, such as a chiropractic clinic or an orthopaedic surgery center, your work will be accordingly streamlined and likely not broken out even further.

However, in the case of a hospital system that handles a large volume of claims over a variety of specialties, you may find yourself assigned to a particular specialty or even a particular insurance payer, as each has different specifications.

If you’re going to become a specialized biller, the knowledge is generally learned on the job through working with multiple payers or practices.

There are certifications available, though they are less commonly required than coding certifications and are not broken down into specialties in the same manner.

Coding specialists generally decide what their focus will be based on the type of care they want to code for or the type of office they want to be employed in.

The American Academy of Professionals Coders offers certificates in a number of specialties ranging from emergency medicine to oncology. The AAPC consistently monitors their offerings and creates new certifications as the industry demands.

For instance, there is currently no exam for mental health, but with the increasing public focus on self care and wellness coupled with 6.7 million adults receiving treatment in 2014 alone, it won’t be long before the industry adapts. So if none of the current options tickle your fancy, just sit tight! The industry is growing.

Coders may also reach out to insurance companies to resolve payment denials, depending on the reason for the refusal. In many cases, a missed modifier, and incorrect code, or a diagnosis that doesn’t match the treatment can trigger a systematic denial.

Sometimes these are correct, and other times, it’s a mistake on the part of the coding team or the transmission system. Medical coders are equipped to assess the situation and appeal the coding, if necessary.

Insurance Company Employment

Medical billing is inextricably connected to the insurance industry, and as medical billing increases, so will the traffic and communication with insurance companies.

Within an insurance company, there will be both customer-facing positions and provider-facing positions, as well as all the internal work necessary to maintain a business.

Customer-facing positions interface directly with patients. These are the individuals that help set up insurance plans, answer questions about benefits, and update patient information when it’s provided. They may also work with a patient to obtain referrals or authorization necessary for obtaining paid treatment.

Provider-facing services are a little more varied. When working with a medical facility, an insurance company will not only be answering questions about benefits and authorizations, but clarifying questions about billing requirements, timelines, and denials.

Insurance companies must also work with providers who wish to be enrolled, or to be considered “in network” for a given plan. This includes negotiating fee schedules, write offs, and reimbursement rates.

Opportunities Are Varied

No matter what your interest in the clerical side of the medical field is, chances are there’s a spot for you in the growing field. It’s easy to start by deciding whether you want to be on the customer service side or working primarily internally for an organization, and then further narrowing your interest by what stage of the process sounds appealing.

In smaller clinics, you may get an opportunity to work all aspects of the revenue cycle, and that can be a great place to start.