The Role of the Professional Medical Biller and Coder

So, what does a medical biller and coder do? To secure timely payment for the provider (that is, your employer or client), you’ll find yourself working and communicating with many different people. As a representative of the office, being friendly and approachable to patients and payers alike is fine. After all, the professional demeanor you exhibit toward patients, fellow office staff, your superiors, and the payers with whom you work goes a long way in helping you establish your role as advocate-in-chief. But you must respect professional boundaries and behave in a professional way at all times.

Whether you are discussing missing patient intake information with the front office staff or making your case to a payer representative after being on hold for an hour, you must temper your frustrations with some level of kindness and understanding. Claims processing is business, and you’ve got to view it and communicate about it objectively, especially when you’re doing the detective work of following up on unpaid claims. No matter who you’re dealing with — your friends in the front office or your new best buddy George from the Medicare help line — stay focused on the facts. Leave your emotions at the door and stick to what’s on the paper or computer screen.

In the following sections, I tell you how to keep your employer/client at the top of your priority list as you interact with patients, payers, and others.

Medical biller and coders deal with patients

Although you’ll spend the lion’s share of your time cozied up to your coding books and software, you occasionally need to interface with patients. In these interactions, your diplomacy chops come in handy. Navigating the sometimes choppy waters of patient relations isn’t always easy, especially when the patient with whom you’re working may be visibly emotional.

In this kind of situation — or in any situation involving a patient — your best bet is to be courteous, maintain your professional demeanor, and focus on the facts. In the following sections, I explain how to handle some of the more challenging interactions you may have with patients.

Patients are the physician’s clients (not yours), so always treat them with respect and empathy. Without patients, healthcare providers would have no revenue, and if they don’t get paid, you don’t get paid.

When the patient can’t pay the bill

In a way, patients are payers of sorts because, in many cases, they’re responsible for at least some portion of the bill you code. For example, a patient may be responsible for a 20 percent coinsurance, meaning she has to pay 20 percent of what you code and bill. (Chapter 6 goes into more detail on insurance plans and the kinds of patient contributions that are commonly expected.)

In a small office setting, you may be the same person who receives a call from the patient who can’t pay her bill, and these issues can be very difficult to address. In this situation, remain professional but be sympathetic to the patient’s dilemma. Here are some suggestions:

• Follow your employer’s rules about contacting patients. Providers let you know when contacting a patient is okay and what method they prefer for this communication.
• Identify yourself upfront. When you call patients, always let them know that you are with Dr. Smith’s billing office or the billing office at Smith’s Clinic.
• Be a listener, not a talker. You don’t need to impart too much information about the inner workings of your client or employer’s office to a patient, if any at all. For example, providers don’t necessarily want their patients to know when the billing company or representative (you) is off-site.
• Explain any available payment plan options. If your office accepts credit cards, installment payments, or financing options, explain those to the patient.

When the patient doesn’t understand how his insurance works

Patients with whom you interact may not fully understand how insurance works, so you may be called upon to explain some insurance basics. This situation often arises when the insurance company sends a payment to the patient instead of the provider by mistake, when a patient receives an explanation of benefits (EOB) statement he doesn’t understand, or when the patient receives a bill from the provider that he wasn’t expecting.

Many such situations arise when patients are out-of-network and, as a result, are often responsible for a large portion of the bill themselves. In these situations, the following suggestions can help you resolve the issue:

• Before making any calls, make sure you know what the provider’s policy is regarding out-of-network patients. If the provider is knowingly treating patients outside of the network, a policy should be in place to address how these claims will be handled.
• If the patient receives a check from the insurance company by mistake, it may be your responsibility to call the patient and explain that they need to surrender the check to the provider. An alternative is to inform the patient of the situation and then bill them for the full charges, explaining that they can use the insurance check to pay the bill. Unfortunately, some patients refuse to surrender the check. In that case, collection agencies get involved or lawsuits are filed.
• Inform patients of payment plan options. When additional payment is expected of the patient, explain any payment plans that are available, including credit cards or financing options accepted by the provider.
• Always be cordial, even when patients may get angry and direct their anger toward you. Don’t allow yourself to be drawn into an argument. Try to remember that the patient’s frustration isn’t personal. Keep your comments friendly and professional, and you’ll do right by your employer or client.

Medical biller and coders work with payers

Your primary goal when interacting with payers is simple: Make sure payers show your client the money! Ideally, your billing software and clearinghouse will keep you apprised of the status of claims (where they are and when they were received) through reports they can generate. The clearinghouse (the agency that relays the claim from the provider to the payer) also generates a batch report that identifies the claims transmitted in each batch. As a result, you should know where every claim is in the process.

Occasionally, however, a claim doesn’t process. In that case, you need to talk to a real, live human being to find out why. When calling a payer to follow up on a claim, you are the voice of the healthcare provider, so always act in a professional manner. Remember, being nice gets you better service.

Make note of the representative’s first name (and the first initial of her last name) when you call to follow up on a claim, and then use her first name as you talk. People like to hear their own names, so repeat the representative’s name back to her. After the rep says, “My name is Sue,” you can introduce yourself with, “Hi, Sue. This is John from Provider Smith’s office. How are you doing today?” Keep the tone friendly rather than confrontational (at least in the beginning). It doesn’t hurt to note the phone number and time of your call either. That way, during subsequent calls, you can use this information to prove that you spoke to someone in the payer’s office; this information comes in especially handy if the payer’s system doesn’t have a record of your call.

Remaining patient

Normally, the payer representative is required to get three pieces of identification for both the provider and the patient. In most cases, the representative asks you for the provider’s name and specific information such as tax identification number (TIN) or National Provider Identifier (NPI) number. You also need to provide the patient name, member identification number, and date of birth. Only after providing this information can the provider representative discuss the specific claim information with you.

Asking for this information isn’t a stall tactic on the part of the payer representative. It’s required by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA guarantees that a patient’s privacy is protected, and only those with a need to know are privy to this protected information.

Getting the resolution you want

Only after getting through the initial step (proving you have a need to know the patient’s confidential information) are you able to inquire about the specific claim in question. Here are some pointers:

• If the person with whom you are speaking is unable to assist with your inquiry, ask to be transferred. When you are transferred to a supervisor, don’t cast blame. Simply describe the issue and the reason you feel that the other person was not providing the resolution you need. Let the supervisor know that you have every confidence that he or she can resolve the issue.
• If you are still unable to resolve the issue, submit a written request and identify the issue in addition to your expectations. Make sure you also define the contractual obligation that supports your position. After you submit this written request, follow up with a call to make sure that the request was received and forwarded to the correct department for appropriate action.
• Don’t threaten or accuse. Instead, stand behind the claim in question and your expectations as defined by any contract or state laws with regard to claim processing and payment. You don’t gain anything by accusing the provider relations representative of failing to process a claim. Instead, ask the representative to help you identify the reason(s) the claim processed incorrectly or was rejected. Make that person your ally, not your adversary.

Any information the representative gives you on the call is not a guarantee of payment (in fact, early in your conversation, the representative should tell you that directly). As always, payment depends on the benefits outlined in the patient’s individual plan.

Medical biller and coders provide positive feedback to colleagues

Part of being a professional is being able to provide positive feedback to coworkers. Let’s face it: Office politics are often (okay, always) at play, so getting along with your coworkers is important. From the receptionist at the front desk to the intake nurse, you have multiple opportunities to keep things positive around the office (even if someone’s driving you nuts).

The success of your job as a biller/coder depends largely on the accuracy of the information gleaned when each patient checks in. Here are some tips on how to get (or continue to get) the info you need from the front desk:

• Make sure that the people at the front desk who are facilitating this process understand its importance, and let them know how much you appreciate the effort they put into getting cooperation from the patients.
• If necessary information is often missing or incorrect, examine the form and see whether you can identify a particular area that makes gathering the necessary information difficult. Discuss the issue with the office manager and diplomatically remind the staff that mistakes on the front end of the claim delay payment.
• If the office uses electronic medical records that employ electronic patient registration, make sure that the necessary information is programmed to the required field.

Most offices that use electronic medical records are contracted with or have their own software support (the Information Technology department). Work with the IT department to make sure that the necessary information is entered.

When discussing deficiencies in an office process or a coworker’s performance, try to use constructive suggestions. The following examples illustrate how to phrase feedback in a positive way. Notice how each identifies the issue and opens the door to a possible solution without accusation or blame:

• “Do you think that we need to revise the demographic form since we’re not always capturing the necessary information up front?”
• “Do we have a contact at XYZ insurance that we (or I) can reach out to for assistance with this issue?”
• “I’ve identified a pattern that shows we’re not differentiating between the AEIOU insurance plans when we enter them into the billing software. Please make sure to check the address on the each patient’s insurance card when entering demographic and billing information.”
• “Dr. Smith usually does not dictate until being reminded. Can we set up a remote dictation system to make it easier for him?”
• “It would make claim submission faster if we had the necessary invoices without requesting them. Can we set up a process to have the invoices copied to the billing office upon receipt?”
• “We can’t submit claims that are waiting for pathology reports. Is there a way for us to access these reports directly through the lab?”
• “If Joe needs help with payer matching, I’d be happy to do it with him.” (as opposed to telling Joe you will do it yourself).
• “Thanks!” The most important sentence of all.