Medical billing and medical coding jobs and careers are easy to start, but hard to find work in. For medical billing, it’s hard to get started because physicians already have someone doing their billing for them. For medical coding, entities are often reluctant to bring on someone with no experience. For both, the training and learning curve is harder and the information more voluminous than most people realize.

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One of the major problems in deciding to do work like this on your own is that no one wants to trust someone without any real billing or coding experience to do work for them. Both of these are harder to do that people who haven’t done it realize. Going to a billing course or coding clinic isn’t enough to make you an expert; both of these careers are way more complicated than people realize.

This isn’t an overly detailed article on the subject, but it should be enough to give information to anyone looking at this as an independent career pause to think about it a lot more before giving it a shot.

Coding

When people talk about medical coding, most of the time they’re talking about diagnosis coding. In a hospital or clinic, there’s a department that usually handles 95% of all the coding; some labs might enter diagnoses based on the scripts from physicians. For a small physician’s group, coding is often handled by the physician. For a large physician’s group, they might hire someone to code their bills.

Diagnosis coding takes longer to learn than billing, and one must be certified in order to get a job doing it. After all, with the implementation of ICD-10 a few years ago, there are now more than 111,000 diagnosis combinations!

Coding Issues

The reason hospitals and clinics are hesitant to hire people without experience in coding is because there are some heavy penalties for incorrect coding. On the fraud list of the Office of Inspector General’s office, a division of the Department of Health and Human Services, is upcoding, which means coding a higher level of diagnosis than what the patient really had. Diagnoses impact inpatient payments, and upcoding gives the indication that a patient received a higher level of care than what the medical record might indicate. There’s a major difference in reimbursement to a hospital if something is coded as a urinary tract infection or septicemia, though both may seem similar to a coder.

Coders also need to know how to code everything in a patient’s chart that may be relevant to the reason they’ve presented themselves at either the physician’s office or the hospital, without adding everything. They also need to figure out which diagnosis is the primary.

Sometimes it’s cut and dry. If a person reports because they cut their toe open, one wouldn’t code their history of heart problems. However, they might need to code diabetes if special treatment needed to be given to stop the bleeding because the person’s foot isn’t healthy due to the diabetes.

Medical Billing

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In general there are two types of medical billing. One is physician’s billing, the other is facilities billing. Facilities can mean hospitals, clinics, nursing home, etc. Physician billing includes clinics, ambulances and the like, and it’s separated by the fact that it’s billed on what’s known as a HCFA-1500 form almost exclusively. Facilities will often use both the HCFA-1500 and the UB-04 for billing, depending on who, for whom, and what they’re billing.

For instance, hospitals mainly use the UB-04, but in some circumstances must submit the other form to collect on some lab services. Overall, both usually bill electronically, so the form isn’t as important as the format and the specific information that’s required for insurance companies to make payment. Medical billing personnel don’t have to be certified.

Medical Billing Issues

There are two main facts about medical billing. One, the work is never done. Whereas a medical coding person could conceivably get caught up and not have to code anything else in a day, medical billing always has more to do.

That’s because, two, not every bill gets paid just because it’s been sent out. There are literally hundreds of reasons medical bills won’t get paid, and it’s up to the medical billing person to figure it out. Reasons can include:

Incorrect charges on a claim
Incorrect codes on a claim
Incorrect personal or demographic information on a claim
Incorrect identification numbers on a claim
Coordination of benefits issues (determining which insurance is primary if a patient is covered under more than one policy)
No authorization number
Missing charges
Incorrect units of service

There’s no one source to learn all the reasons medical bills aren’t paid. It’s all done on trial and error and time. Sometimes even the explanations of benefits aren’t explanatory enough. A lot of time is spent calling both patient’s and insurance companies trying to get information and to get bills paid. Without having the knowledge or background of what to ask and how to follow up your accounts receivable is going sky high, cash will be low, and everyone will be stressed.

Costs of Starting Either Business

The costs for starting both of these businesses can be relatively low, though much lower for medical coding. A medical coder can start a business with an ICD-10 manual book and nothing else, although purchasing coding software would reduce the time it takes in arranging codes properly.

Medical billing will cost a little bit more, although it should cost a lot more. The person would have to purchase both medical billing software and paper forms. Because of the paper file cabinets would be needed, although these days most insurance companies want to receive bills electronically. Software can range from around $500 all the way up to $10,000, but you have to know what you’re looking for. What happens too often is someone buys the cheapest thing around and then has no idea how to use it properly.

Self employment isn’t an easy endeavor, and getting into the health care financial industry without experience is a terrifying prospect. It’s always best to see if you can get some real experience before thinking about embarking on your own.
 

Years ago I read a news story titled “The Check Is Not In The Mail”. It was a fascinating story about a health care organization called Athenahealth that did a brief study on how the nation’s seven biggest health insurers pay their bills. What they found wasn’t shocking to anyone who’s ever had to try to collect on hospital or physician’s bills for a living.

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They had incidences of companies saying they didn’t have copies of their bills, even when the provider had a signed copy of a registered receipt. They had insurers telling them that they were limited to only so many questions per phone call. I’ve dealt with many of these issues over the years.

The story also talked about some of the excuses payers give in delaying the payment of claims, and how it ends up costing providers in time and expenses on the back end, with most of the costs being passed along to the patients. It mentioned that at least 40% of the denials can be tracked directly back to poor or incorrect information being sent by the providers; that’s a statistic that drastically has to change for health care providers, especially in today’s world where proper information can get claims paid faster.

What also wasn’t particularly surprising was how quickly representatives of all the insurance companies were to dismiss the findings as unscientific, while also claiming just how proficient they really are, based on the number of claims they have to process on a regular basis. I remember having local insurance companies state that all claims are processed timely, and that there’s no reason to ever have to call an insurance company because all will be handled in a timely manner; yeah, right!

The real world doesn’t work like that, as most of us know. We have valid reasons for picking up the phone and calling insurance companies to ask them where our payments are. When I see someone touting that they average time for paying claims is 30 days, I’m reminded of the fact that average means there are some claims that ultimately take much, much longer, and those are the ones that drive up our days in receivables. I also know that it varies from state to state, so whereas a state like New York says claims must be addressed (that’s an important distinction between being “paid”) within a certain period of time, that rule doesn’t cross state lines all that often.

Outside of providers who net their receivables at the time of billing (which is misleading and dangerous in my opinion), how many of you out there are actually averaging even close to 40 or 45 days in receivables? In all the years I was a patient accounting director, I hit 44 days during one absolutely great stretch that lasted about two months, totally gross receivables, before one of my billing people left to take another job. I wasn’t allowed to replace her for another 4 months after that; it never happened again.

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That was with our lag time of six days before dropping bills so medical records could get them coded. Even when things were going well, we had claims that were over 90 days in receivables that had nothing to do with self pay; we even had some claims still sitting out there over 360 days. Is there anyone who can’t identify with that?

Since it’s fairly obvious that the insurers aren’t going to willingly accept any blame for their shortcomings, and, as most management and motivational speakers will say over and over, that one can only change themselves, once again we need to take a look at what the providers can do for themselves to help get their claims paid quicker and easier. The following are some things you should look at, or have verified, to help out.

1. Know your insurance contracts.

Most of us try to learn everything we can about Medicare regulations, but after that things start to fall apart. Every one or two years, there’s a new contract with most insurance companies, and almost always something has changed. Since most of the time your contracts are negotiated by someone who really has no grasp of the billing process, you need to try to find out as much as possible as it regards these contracts.

Each month, the major insurers usually send out some type of bulletin describing changes they expect to see in new bills being submitted. Oftentimes, this information, if read at all, isn’t passed along to the people who are responsible for these claims; that needs to change. Much of the information, old or new, can usually be found on the insurers website, but too often employees are blocked from using the internet at work with worries that they’ll be doing other things instead of working.

On one of my consulting assignments, in discussions with a major state payer, I learned that there was a system error for this particular insurer that had gone on for upwards of two years that very few people in the state knew about, yet it was posted on their website. The error message on the explanation of benefits didn’t allude to where the information could be found, and the people responsible for this insurance company at the hospital I was consulting at never thought about picking up a phone to call and find out what the error message meant. If someone had been monitoring the online directives, or even been allowed to use the internet to access the website, they would have discovered this particular error sooner.

2. Request a review of your charge master, or do it yourself.


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It never ceases to amaze me how many charge masters have revenue codes ending in “9”, which designates “other”, or unknown services, instead of the correct revenue code, or even the generic revenue code category. This may be fine for your major insurers if it’s in the contract, but it gives other insurers a good reason to deny or delay payment on your claim.

There are many procedures that need something else to be billed along with it to be considered for payment. Things like not billing anesthesia when you have recovery room charges, not billing an expected C-code item with a procedure, or not billing a pharmaceutical along with an injection, will delay your claims.

Coding an item with an improper revenue code in order to get it paid, while knowing that it’s not exactly proper (as in coding something as a clinic because you’ve contracted clinic payments, but you know it’s not a clinic), is not only improper but fraudulent, and it could get someone fined or jailed. Pleading ignorance may work, but it usually doesn’t. Verifying that your groupings are correct, such as making sure your supplies aren’t coded as procedures and vice versa, is crucial. Making sure that all the services you bill have a price on them won’t hurt either (surprising how often I see that).

3. When reviewing unpaid claims, be thorough when verifying demographic and billing information.

I can’t count how many times my mother had to call the provider of services for my grandmother years ago because they’d put my mother’s name on as guarantor, since she handles all my grandmother’s bills and was always the one making the phone calls. The bills often got denied and had to be rebilled because of that error. Easy things such as the incorrect sex or date of birth are inexcusable, but happen on a regular basis. Verifying primary insurance for a child or someone of Medicare age is critical. Checking active dates of service can save you time and embarrassment.

4. Don’t be afraid to pick up the phone and call someone.

Patient or insurance company, your role is to get your medical claim paid. If you need correct information, or need to find out the reason a claim isn’t paid, sending a letter is the easy way but also takes a lot of time.

In the scenario I mentioned on point number one, the acting supervisor didn’t want to call the insurer, hoping there was another way around the issue, but also wouldn’t let the billing personnel call either. Without calling the insurer, we’d have never had the answers that were needed to correct the billing issue, and I wasn’t about to do what was requested of me without confirmation from the insurer (which I knew was illegal and had confirmed by making that phone call). It’s always better to get it right than to continue getting it wrong; it’s certainly more financially beneficial.

Someone has to step to the plate and be ready to accept responsibility for getting claims paid more timely. If the insurers aren’t going to cop to their part in the process, the least medical billing departments can do is minimize their own errors and lack of proper processes.
 

Last year we had an article here talking about reasons to consider assisted living. It was more about the needs for assisted living and the potential emotions associated with it by the residents.

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This time around we’re going to address issues around assisted living centers that most people don’t know, things that may help you decide if it’s the place you want to put your loved one into. After having to go through the process with my own mother I’m sharing some of what I’ve learned.

1. Assisted living organizations don’t take insurance

Assisted living isn’t a senior care center. The idea is for it to be a place for those of a certain age who can pretty much take care of themselves but might need some minor assistance. Many of them might be older, but that doesn’t necessarily mean they’re not pretty healthy.

Because of this, insurance isn’t going to cover any of the bills; at least not those generated by the assisted living center. They will help coordinate visiting nurse services if requested by a physician, which will be covered by those of Medicare age. Otherwise, it’s going to be totally out of pocket at this level.

2. How much money you have to spend monthly

Believe it or not, this is the 2nd most important thing to know, even moreso than what the monthly rates are. Many of these facilities are going to want to set up automatic withdrawal, which means you need to make sure the resident has the funds to last them for a long time. The income level is going to need to be somewhat significant; don’t even think about looking into assisted living if you can’t spend at least $4,000 a month. This isn’t all “fee” though; I’ll be addressing more below.

3. How much monthly rates are

This is actually the 3rd most important thing to know. Assisted living fees are different across the country and even across your own area. I live in the Syracuse NY area and fees run from between $2,300 and $4,800 a month.

As you can imagine, the least expensive fees are probably in large facilities in urban areas, and the most expensive fees will be in very nice settings with a bit more exclusivity. But wait; there’s more.

These facilities will have rooms of different sizes, from studios to 2-bedroom “suites”. Don’t think apartment sizes for these prices; they’re probably less than half the size of a traditional 2-bedroom apartment.

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One that I looked at had what they called a studio apartment which was 100 square feet; that’s the size of a small home office. It didn’t include cable or phone, but it did include heat, and since older people are always cold this might not be a bad feature. Meals and activities will be included in the fees, along with some limited travel and transportation to doctor’s appointments or to the store if you request a small refrigerator in the room.

The more you can spend, the nicer a place you can get, but you’re going to want the resident to have enough spending money to enjoy themselves.

4. How nice are the facilities

Once again this is based on location and price, but even pricey assisted living centers might not be all that nice. There was one assisted living facility that was very spacious and well laid out. It had multiple sitting rooms and game rooms, and even an exclusive room where there was a piano and extra large TV for movie night.

The big spaces can be really nice. Other spaces might seem a bit oppressive. Some residents might end up having to share a room, just like in a hospital, and that’s not always a pleasant experience. Also, some facilities aren’t as clean as you’d hope they would be, especially if they have a lot of residents. Unfortunately, most of the people working in these larger places don’t make a lot of money, so it’s hard keeping quality help.

5. What recreational opportunities do they have?

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You like to know that your family member will be mentally and physically engaged instead of having to sit around watching TV. Most of these facilities will offer games, dances, sing alongs and movies, but the larger the places are, the less likely they’ll be in making sure everyone participates as often as you’d hope. Smaller facilities have employees that get to know the residents pretty well, and in those cases the residents will be encouraged to participate in these things more often. By the way, this one comes from talking to residents of different facilities and their experiences.

6. What are the meals like?

Some assisted living facilities have almost world class chefs and fancy meals and desserts. Some will have standard comfort food, while others might have sandwiches and one daily special for lunch or dinner. No one will starve, but the food might not be all that flavorful since dietary concerns become the norm.

Also… well, this one’s not quite fair, but it was an observation I had at one facility. There was a large dining room and I was there during lunch. Half the tables had residents who were still in their night clothes or robes, and sitting at tables either ignoring each other or just looking… old. A few tables had great engagement and laughter, but strangely enough those tables were all male. I’m not sure what that says overall but I have to admit that it gave me pause, thinking that my mother might be at a table where no one was talking or showing any life.

7. Are there hidden fees?

This one is the most important thing you have to find out about. Many facilities will offer different levels of care based on tier pricing, in which case you know what’s going on up front. One of the facilities I looked at gave us a price list of extras, and some of them seemed a bit outrageous. Since they determine which extras your family member might need to receive, it’s possible that your monthly bill could end up being as much as 300% higher than the actual monthly rate… being automatically withdrawn without your prior approval. That will eat up savings pretty quickly.

Truthfully, it was this last one that convinced my wife and I to move my mother into the house with us. It’s turned out to be the smartest move, and we can make sure that her money is safe and that she’s well taken care of.

Most people will have to think about assisted living at some point in their life. I hope this has been helpful.
 

Just like almost all businesses large enough to have employees pay someone to audit their businesses, hospitals sometimes need to, or should have, someone come in to audit their receivables process. It can involve looking at the charge master or how charges are captured, or a host of other things. This article is specifically going […]

Every person who works with hospital bills know something about revenue codes. Some folks have at least a basic concept of what revenue codes are supposed to be, that’s about as far as it goes. Scarier yet, some people have only heard the term. It would seem that it’s time someone addressed revenue codes in […]