Answers to Common Medical Billing Questions

Some common medical billing questions and their answers, including where to look for more help...

After you get your education and certification and formally enter the world of medical billing, you'll probably still have a lot to learn. A lot of your skills will come from on-the-job training, such as how to juggle all of your responsibilities while the phone is ringing off the hook, or while your office manager is always asking you to do something else.

But there'll still be many unanswered questions about your job.

Some of these questions will raise their heads early. You'll have to answer them before you can continue. Other times there'll be lingering questions which you may never quite figure out the answers to.

But not to worry... here are some frequently asked medical billing questions by those new to the field.

Medical Billing Basics

Medical Billing Basics
Want to quickly get to grips with the fundamentals of medical billing? We recommend the ebook The Basics of Medical Billing, a guide to the industry written by a mother/daughter team of billers. Learn more about it here.

What are the governing agencies in medical billing?

There are a few governing agencies in the healthcare industry, which regulate the way you bill and send claims and appeals. These agencies also govern the way insurance companies deal with providers, such as responsiveness and communications.

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These agencies also have a lot to do with the way the healthcare industry runs and have answers to many other questions you may have. Also, if you are having problems with an insurance company, these agencies will help you communicate with that insurance company.

Two of these agencies are national:

  • CMS, the Centers for Medicare and Medicaid Services
  • CDC, the Centers for Disease Control

If you have a question about the way Medicare works or a new regulation on a disease, these are two agencies that you need to contact.

There are also many more state or local agencies:

  • State Medical Association, a state agency that can help you communicate between insurance companies and providers, as well as teach you about new insurance regulations and billing guidelines.

  • State Department of Health, which governs the legal aspects of medical management. This includes regulations on vaccinations, disease control at the state and local levels, and special state requirements which are important for your medical practice.

  • Other Medical Associations, such as the medical associations that concern your medical specialty. For example, the American Academy of Pediatrics is the agency that helps you manage a Pediatrics practice, as well as answer any questions specific to managing and billing in a pediatric practice.

See our guide to important medical billing associations.

How do you know whether or not what you're doing is right?

If you have questions about whether or not you're billing claim correctly or if your office's practice are legal, you can contact one of the above agencies. They'll help answer your question.

Don't be embarrassed to ask medical billing questions when you are just starting out. Many medical billers and practice managers may not be the most knowledgeable people in the industry. Unless they've received a formal education in medical billing, chances are that they have some misunderstandings that need to be corrected anyway.

It's always better to be safe than sorry when you are dealing with patient's healthcare and possibly doing your job wrong!

Where do you go when you are having a problem with an insurance company?

Don't be embarrassed to ask questions when you're new

If you have worked in medical billing for a few years and have never had a problem with an insurance company, you are very lucky. Many times, insurance regulations change without notice, so you'll unexpectedly begin receiving denials of claims that were previously paid in full.

If you have questions about why the claims were denied and how to refile them, you can call the insurance company for more information. Usually, these claims can just be corrected and refiled.

If you're having a more serious problem with an insurance company (e.g. you have filed an appeal numerous times and have not had a satisfactory response) you have a couple of options.

Your first option is to call your insurance provider representative. When a provider contracts with an insurance company you'll be assigned a provider rep. This person helps answer any questions that you have about the insurance company, your contract, and your claims with that insurance.

If you're having a problem with getting an appeal paid correctly, you may be able to contact your rep to have them look into it and fix the problem.

Your other option would be to file a complaint about the insurance company directly with your state medical association. Your state Medical association exists to help bridge the communication gap between national health agencies, state providers, and insurance companies.

If your complaint is serious enough the medical association may decide to engage in legal action against the insurance company or conduct an inquiry into the insurance company's practices.

What if you're worried that your office is involved in medical billing fraud?

Medical billing fraud is a very serious offense. Whether or not you do it knowingly, if your office is engaged in medical billing fraud you are also partly responsible.

Like before, it's always better to be safe than sorry. Try everything you can to make sure that your office is staying legal. Talk to your supervisor and the doctors to make sure that each and every one of them knows your concerns.

Whether or not they make a change, do not engage in medical billing fraud. Even if it costs you your job, it's still better than going to jail or paying a huge fine!

If talking to your supervisors doesn't help, your only recourse is to report the fraud. You have to report the fraud to your state medical association or department of health, which will be able to help conduct an investigation and elevate the situation if necessary.

Other Medical Billing Questions?

Chances are that you'll always have more questions about the healthcare industry and medical billing. It changes constantly, so being confused every once in a while is inevitable.

Don't be embarrassed to ask questions wherever you can until you the get answer you need!

If you have a question for the team don't hesitate to contact us. We'll answer your medical billing questions then put them on this page for other readers to see.

We also recommend the ebook The Basics of Medical Billing for getting a good grasp of the industry.

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