The indispensable Role Medical Coders and Billers Play in the RCM Process

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Oct 20, 2022

The indispensable Role Medical Coders and Billers Play in the RCM Process

Medical billers and coders play an indispensable role in the healthcare revenue cycle process, connecting healthcare practitioners, the patients they serve and the insurance companies that reimburse the medical expenses. Whenever you visit a clinic or when you are treated by a doctor for pretty much any reason a medical record is created. But how do they get paid? It is here the role of medical coders and billers comes into play. The medical coder turns the medical record into billable codes. The medical biller in turn uses these codes and sends out the bill to the insurance provider for timely and accurate reimbursements. In short, they both work together to ensure that physicians get paid in full and on time for the services rendered by them. Most importantly, billers and coders do their part to ensure that physicians focus on providing quality care without having to worry about insurance payments.

Typically, both medical coders and billers work behind the scenes of every hospital or clinical setup. Let us in this blog explore what exactly a coder and biller are, their roles and the consequences of incorrect coding or billing.

Who is a medical coder?

A medical coder is a person who analyzes medical reports and converts them into uniform medical codes. You may wonder why codes are assigned. Well, common language may not provide the insurance company with the accurate information they need. That is why a set of specific codes have been established to identify medical services and procedures. A coder may work in a variety of settings, ensuring that every bit of patient information is coded in an accurate and consistent manner. The specific codes they assign help the biller to create a claim and send it out to the insurance company.

Role of a medical coder

Generally, the medical coder and the biller can be the same person. However, this role can be performed by two different persons, one coder and a biller who work together to ensure that practices receive full and timely reimbursements. A medical coder reviews medical records and assigns appropriate codes to ensure that healthcare providers get reimbursed for their services. The role of a medical coder is not easy as it may seem. In the first place, they have to carefully go through physician notes to find out what type of service the patient has received. Secondly, a good understanding of payer rules and policies is crucial in order to ensure accurate and compliant-rich coding.

The following are some of the roles and responsibilities of a medical coder

  • Carefully examine the patient’s file, pull out vital information and convert them into appropriate medical codes required by insurance companies

  • Follow best practices to ensure use of right codes. Usage of the right codes ensures that insurance companies are billed the right way

  • Code the entire story of the patient's visit – from diagnosis and treatment to the medical supplies used and medications given

  • Ensure that the codes used are current and active

  • Communicate as and when needed with healthcare providers, insurance companies or other payers

  • Get in touch with healthcare providers to clarify or get any additional information in order to code to the highest degree of specificity

  • Lookup for information in case the coding is complex or unusual

Consequences of errors in medical coding

Any error in coding not only leads to financial losses for the healthcare provider but also significantly impacts patient care. Failure to assign the right codes can also lead to delayed, partial or denied reimbursements which can greatly impact practices’ revenue stream. Not only that, it involves a lot of time and effort to identify the root cause and resubmit a claim. Sometimes insurance companies may not agree to pay in full and opt for a partial payment. And to make things worse, inaccurate coding can account for HIPAA violations, penalties, fines, lawsuits and sometimes even imprisonments.

Who is a medical biller?

A biller is a professional who submits bills to insurance companies and ensures that the healthcare providers get paid for the services rendered. After evaluating the bill the insurance company decides how much to pay and returns the bill. Now that the insurance has been deducted, the biller figures out how much of the bill the patient owes.

Role of a medical biller

  • Prepare, verify and submit claims to the insurance providers

  • Make sure that all patient information is accurate and up-to-date

  • Follow-up on the bill until the provider gets the reimbursement amount

  • Generate statement and collect outstanding balances from patients

  • Investigate the reason for every denied claim and file an appeal with the payer

  • Verify the details of the bill to ensure accuracy and completeness

  • Follow-up with the insurance company in case of payment discrepancies

  • Help patients in setting up payment plans

  • Get referrals and preauthorization for patient procedures

  • Confirm patient eligibility and verify benefits

  • Maintain billing software to update cash spreadsheets, rate changes, and current collection reports

Consequences of errors in medical billing

The medical biller submits claims directly to the payers, which contains pertinent patient information, procedures performed, the diagnostic codes, the cost of the procedure, provider details, practice details and much more. Incorrect information can pave the way for claim denials. Some of the examples of incorrect billing include coding errors, duplicate billing, delayed filing and incorrect patient details. Misrepresenting diagnoses or procedures to maximize payments and billing for procedures separately instead of bundling under a single CPT code accounts for healthcare fraud.

Medical coders and billers make sure that healthcare providers get adequate and timely reimbursements for the services they render. It is important that healthcare facilities have a team of skilled medical coders and billers who are experienced in the specialty you deal with and stay current with the medical coding and billing updates to avoid issues with errors. All of this involves a lot of time and administrative work that could otherwise be spent providing quality care. That is why healthcare providers choose to outsource their medical billing needs to professional companies like Scribe4Me which has an experienced team of coders and billers. Sounds interesting? To learn more about our billing services get in touch with us today.

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