The importance of the healthcare system has increased since the outbreak of the COVID-19 pandemic, and it has put a significant strain on healthcare providers. Both medical billing and coding help ensure that healthcare providers provide timely payments for their medical and clinical services. Medical billers and coders act as the middlemen between healthcare providers (such as Sutter Health, Kaiser Permanente, and Sharp Health) and health insurance companies (like UnitedHealthcare, Anthem, and Aetna), as they generate accurate and efficient billing for patients. Because of this purpose, both medical billers and coders must act in tandem, ensuring that they bill patients the correct amount.
Medical coding and medical billing are two different positions that require some degree of training (such as a certification or an associate degree) due to the specialized training. Both professions are amazing opportunities for individuals looking for a remote position because there are employment opportunities with healthcare providers, insurance agencies, or medical billing agencies. Another option is for a medical coder/biller to work freelance, where they can work off of contracts with medical facilities or agencies.
What Skills Are Needed
Aforementioned, medical coding and medical billing have different job requirements, but both require the specialist to possess certain qualities:
- Knowledge of HMO/PPO plans – While both HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) are plans determining a patient’s ability to see providers and the coverage for out-of-network services, they differ in costs, as well as the services they are able to provide.
- Good communication and interpersonal skills – particularly in high-stress situations involving rejected insurance claims and billing discrepancies.
- Proficiency in mathematics and computer skills – database software, such as Electronic Health Record (EHR) systems and medical coding and classification programs (ex. Healthcare Common Procedure Coding System [HCPCS]), will typically be used. Other examples of technology used include word processing software and data-entry software.
- Decision-making skills – vital to analyzing medical records to determine the best way to code them for the patient’s medical records.
- Attention to detail – to accurately record and code patient data. MedDRA, the standard medical dictionary resource used by pharmaceutical medical coders, contains more than 70,000 terms, so it may be near-to-impossible to recognize which is appropriate to use in a given situation may be difficult if you do not have a keen eye to detail.
Difference Between Medical Billing and Medical Coding
Medical coders are typically the first people to view a patient’s medical record, which commonly starts as soon as the patient encounters their healthcare practitioner (ex. A doctor, podiatrist, dentist, optometrist, clinical psychologist, or nurse practitioner). This healthcare provider specifies the services, procedures, and items used during the patient’s stay in the healthcare facility. By law, providers are required to use clinical documentation for the treatment provided, which can then be used as evidence if an investigation ensues due to a conflict in the claim. Once the provider discharges the patient, their medical record is handed off to the medical coders, who then review and analyze it to formulate connections to billing codes related to a diagnosis or procedure.
Once a medical coder finishes determining the billing code, the medical biller takes over. The medical biller records insurance claims and transforms the billing code into a formal bill, once again ensuring that the medical information is accurate. This bill is then brought to healthcare insurance companies so that they can settle the details, plan any denials/rejections, and then send out the statements to the patients.
AI in Medical Billing/Coding
As with many professions, Artificial Intelligence has been implemented in medical billing and medical coding to help identify and extract data from medical records and apply the appropriate code(s). But this software is not intended to steal jobs away from medical coders and medical billers, especially since the U.S. Bureau of Labor Statistics believes that the number of medical coding jobs will increase by 8 percent between 2019 and 2029. The software is intended to prevent costly mistakes such as inaccurate billing due to inaccurate coding. The software can also keep up with the new codes and the necessity to process as many charts as possible, which cannot be accomplished by medical coders/billers alone.
The healthcare revenue cycle also reveals the need for this AI, especially since audits typically occur too late in the revenue cycle, limiting their usefulness. For example, the patient may already be paying off their bill by the time the audit has occurred and revealed the coding inaccuracy. The fact is that audits must occur frequently and quickly.
The AI software also alleviates the workload medical coders have, allowing them to focus on more meaningful work – or work that AI has not been able to assist with – such as spotting trends based on the diagnoses being reported.
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Written by Alexa Do