Ask the Medical Billing Specialist

Miscellaneous and Personal Stuff I Must Share
1

I hope this is the right forum, but it didn’t seem likely to dissolve into something that should be over in GD, so here goes:

I am a Medical Billing Specialist, currently working for an ENT/Surgery practice. I have 4 years of experience in the field in general, but I am most familiar with “commercial” insurance (aka “third-party” insurance) and Indiana Medicaid. I do have, however, more than a passing familiarity with Medicare & Medicare suppliment policies. I am also familiar with the pre-certification/referral procedures for most insurances, as well as Durable Medical Equipment (DME), prosthetics & orthotics.

Some caveats: IANAD, so I can’t (won’t) answer actual medical treatment questions. I am not familiar with either dental or pharmacy coverage other than what I currently have, so I probably can’t answer any more than the most rudimentary procedural questions. And, to be fair, I am HEAVILY biased AGAINST most of the big insurance companies and the current state of “managed care” in the US. (Please do not hijack this thread into a “how do we fix the healthcare system” thread…there are plenty of those over in GD.)

However, I’m willing to answer questions about things like what you should know/do before you or a family member has surgery, the appeals process when a claim is denied, general coding questions, translating Explanation of Benefits forms, insurance terms, etc. If I don’t know the answer, I’ll say so.

That being said, ask away. :smiley:

2

How did you get into the field? What kind of education/training did you need?

3

Is there any “statute of limitations” for billing? (Either for a doctor’s office, or for an insurance company to demand money back for something they shouldn’t have covered.)

4

I actually got into it by accident, originally. I was given a temporary assignment at a hospital in Detroit, and had some really good on the job training. I’ve since worked at another hospital, a DME supplier, and the practice I currently work at.

A lot has changed since I got into it; when I started in 1989-1990, there weren’t as many managed care plans, and things were done a little differently - but not much.

I would recommend a background in medical terminology at the least, and some coding classes are also a good idea. A lot of it is practice, and hands on experience. I’ll try to think of some good websites for you to check, if you’re interested.

5

If Indyellen doesn’t mind, I can field this (I work in the insurance billing department at a large hospital).

The answer is: depends. If the facility has a contract, filing time limits will be there. The insurance company will not give a flaming rat’s ass WHY you didn’t file in time. You snooze, you lose. Same can be said for the insurance company asking for a refund.

I’m now in the Contract Management department (a raise and a promotion, woo-hoo!) and I’m starting to see how the contracts work. Some plans pay by CPT codes while others are based on HCPCS coding. Others, still, will pay by a percentage or per diem rate.

For insurance companies that don’t have contracts, one year is usually the norm. I think it depends on the state.

6

Well, as far as on the doctor’s office end, most insurances have a filing limit of one year from date of service. However, that can vary by contract & plan - we have one Medicaid plan here in Indiana that has a 120 day filing limit, and a 60 day appeal limit on denied claims. You can, occasionally, extend the one year filing limit based on how many responses you get back from the insurance company.

What impacts it on the insurance end varies from state to state, based on their Department of Insurance & Secretary of State guidelines. If it is a group plan, it is regulated by the Dept. of Insurance and if you don’t receive a response or receive an inappropriate response, the doctor, the patient, or both can report the company to the Department. If it is a self-funded employee plan, it’s governed by ERISA and only the employee can appeal final decisions to the Department of Labor.

However, the government can do (mostly) whatever it likes: Medicare has been known to come back as many as 2 years later and recoup monies paid in “error.” (Which means sometimes it’s really an error, and sometimes they just think it is.) shrug They’re the government.

If it takes your doctor a year to get your claim paid, you might receive a bill somewhere down the road for the co-insurance or deductables. Some doctors will have you sign a financial policy stating that if they haven’t had a response from your insurance within a certain amount of time (usually 60 days or so) then they may release the bill to you (the patient) and you will be responsible both for payment and getting your own reimbursement from the insurance company.

Our practice tends to work on things a lot longer than, say, a hospital or a large family practice, but that’s how our doctors want it.

Keeps me working. :wink:

7

I don’t mind - nice to see I’m not the only Doper Biller out here. :wink: There is, I’ve found, one good reason a company might waive the filing limit - if the patient didn’t inform you (for whatever reason) until late. And that’s not a “cast iron guarantee” sort of thing.

I think in most states, there is a limit to how far out the insurances can ask for their money back.

Oh, and our practice has some capitated contracts - ugh. Pain in the butt. I suppose in some cases they’re a good thing, but to me they’re a pain.

8

Is there a reason (other then corporate greed) why the bill gets process right away but refunds take 1 day short of forever?

A story: a couple of years ago, I went in for an ankle x-ray for what turned out to be a severe sprain. The receptionist forgot to write down my insurance information, so about 2 weeks later I got a bill in the mail. I paid it, thinking it was coming out of my deductable. About a month later, I got another bill, this time for the x-ray tech. (Perhaps that’s a second question, why can’t they bill me for everything on a single bill and be done with it?) Thinking something was odd at this point, I call the clinic, and they tell me they don’t have insurance information for me. Well, I certainly corrected that situation, and they said that I’d be issued a refund for most of the first bill that I paid, over $100. Long story short, it ended up taking nearly a dozend separate phone calls and almost a year before I finally got the money back.

Is this situation common in your experience?

9

Can you work at home doing it? Does it pay decently?

10

Well, in my experience it may not be corporate greed at all. In the case of our practice, my manager (head of billing) is only allowed (approximately) $3000 per month to pay refunds back, due to overhead & other current ongoing costs (my salary, for example.) If you consider that there are possibly refunds due to both patients AND insurance companies, and a single refund may be anywhere from $5 to $1000+, some months there’s not much we can do. We certainly can’t pay back every refund every month. It’s not possible. And if the refund is due Medicare or Medicaid, those are going to take priority over EVERYTHING, even patient refunds. The gov’ment gets NASTY.

So, if you’ve paid something you shouldn’t, and you’re dealing with a practice on a budget, they may not be able to do anything about it - even when you call and request it. I don’t know how it works for hospitals, etc. - that has a greater chance of being corporate greed, IMO, but I’m sure the have a budget to work with, too. Mr. Blue Sky seems to have more hospital experience than I do; perhaps he’d know.

I think the thing to remember is that while its “the doctor”, your doctor is having to run A BUSINESS, and sometimes has to make decisions the same way any other business would.

I’ll answer the second question in a separate post.

11

jweb:

Well, that’s a very good question. The reason is that it’s not actually the hospital/clinic who technically provides all the services. The facility bills under one tax-id number, and so they will bill you. The radiologist bills under a DIFFERENT tax-id number, and will bill you separately. If you saw your doctor, who sent you to have these tests done, your DOCTOR probably is being billed under a third tax-id number, and will bill you separately for your office visit. In many cases, each one has its own billing company/department, who bills the insurance for each, then you. And while they SHOULD BE getting your insurance information from the original referral source, some auxilliary services don’t bother. They consider it patient responsibility to make sure they have the information.

And if you belong to a managed care plan, they MIGHT NOT all be “in network” for your insurance - each facility/practice/billing service has its own contract (or not) with the insurance companies, too, with different fee schedules.

For example, if you are going to have outpatient surgery, you will (at some point) probably have bills from the following:

[ul]
[li]Your surgeon, for performing the surgery.[/li][li]The facility where the surgery was performed, if not in the doctor’s office.[/li][li]The anesthesiologist, if general anesthesia is involved.[/li][li]The lab, if you needed lab work done during or before the surgery.[/li][li]The pathologist who reads the labs, if they are sent out for reading.[/li][li]The radiologist if the doctor needs x-rays, CT scans, etc. to perform the surgery.[/li][/ul]

That’s just the bills I could think of off the top of my head. And again, any or all of the auxilliary providers might NOT be “in network” for your health insurance. That’s why pre-certification is SO IMPORTANT…and don’t count on your doctor to be making sure all of these other people are “in network” - that’s not actually the doctor’s responsibility - it’s YOURS, as the patient & insured.

Not optimistic, but I hope it answers the question.

12

I’ve never worked at it from home, so I honestly don’t know. I know there are people who do, and seem to make a decent amount. I know of more people who do medical transcription from home than medical billing, but I know it’s possible to do both. I’ve seen some good sources out there; I think if you’re really interested in doing that, you can Google under “medical billing home” and find some information out there. I just can’t remember any off the top of my head. :wink:

For myself, because I work for a small-ish practice, I make less than is considered the median income for my area, but I like the environment, so it’s not bad. Not a great living, but not bad. It varies based on experience. My main problem is our benefits SUCK because we’re a small business & the premiums are through the roof. I lose a lot of income paying my medical insurance premiums - and I’m in the business. :rolleyes:

Hope that answers enough.

13

How do you bill “removal of anal obstuctions”? :stuck_out_tongue:

14

Would you agree that TriCare’s existence should be terminated… terminated with *extreme *prejudice?

15

:rolleyes:
CPT (procedure code) 45915, remove rectal obstruction. That’s the closest I can get. Yes, it’s a straight answer. I do have a sense of humor…see below.
Your proctologist called. He found your head. :smiley:

16

Well, I would have to agree with you when I was having to deal with Humana as the plan administrator. However, my region is now managed by Palmetto GBA, and they actually know what the !*&$# they’re doing.

It truly depends on the plan administrator/manager. They seem to cover a reasonable amount, at least for what I’ve dealt with. But Humana…
:rolleyes:

I do have a list of prospective firebombings (if I were that sort of person) of insurances I would take out with EXTREME PREJUDICE. TriCare doesn’t happen to be one at this time, but they used to be.

17

We try to get refunds due to patients out as quickly as possible. Once we’ve verified that refund is due (maybe you paid a co-pay when you didn’t have to), a check is usually sent out within a week of the refund request.

Refunds to insurance companies can take little longer. Some companies we are contracted with will take the money back without asking and we have to fight them to get the money.

Tricare can go back TEN YEARS and take money back!!

18

I think the key there is refund request, a lot of ours haven’t ever been requested, and we use up our budget paying out the requested ones. (IMHO our practice is particularly bad about it, but you didn’t hear me saying that.)

Like I said…the gov’ment is BAD. Although I believe I’ve heard from some of the coding/billling listservs I belong to that states can regulate that to a certain extent, except maybe with Medicare.

Thanks for pitching in, Mr. Blue Sky

19

Sorry, let me clarify, our refund clerk will send a request internally to get it approved.

You may not know right away that you are owed a refund. As soon as we find out (reports are run on a regular basis) a refund is due, we verify it and send you the check. You don’t have to ask. The insurance companies, OTOH, MUST ask. No, we aren’t complete bastards, mind you, it’s just that the insurance companies are usually the ones who screwed up and overpaid due to their own negligence.

We are more concerned with having happy patients than happy insurance companies.

20

Former radiology coding/billing specialist here.

In my experience, it is no longer possible to do this at home. Thanks to HIPAA, there has been a huge crackdown on the confidentiality of patient health information. My practices basically adopted a policy that nothing with patient information was to leave the office. Much of this can be done electronically, but few, if any, practices are willing to invest the kind of money it takes to ensure that information is securely transmitted.

As to pay, it depends on who you work for and where you live. Large practices and hospitals tend to pay more and have better benefits than smaller practices. I’ve made anywhere from roughly $10 to $15 an hour.

In terms of education and training, it’s better to go through a community or technical college. This ensures you will be able to take certification exams, which may be required by some employers, and it gives you a leg up on people who don’t have formal training. Since most colleges have job placement offices, it’s easier to get job leads, as well. The other benefit to community college is that you may be eligible for financial aid or job training assistance. To be honest, those home-study courses that advertise on TV are a waste of money. I’ve never known anyone who took that course who actually got hired.

Robin