Medical Billing Specialist Duties and Billing Process

Touseef Riaz

November 3, 2020

medical billing services near me

If you work in the healthcare sector, you will likely know that medical billing is a dynamic and fast-paced job. A medical billing specialist should have the ability to focus as well as pay attention to detail to do a good job. Did you know that medical coding and medical billing specialists work in one of the fastest-growing occupations in the US?

As both full-time and part-time opportunities are available in many settings, such as work-at-home options, note that a job in this quickly growing industry may be ideal for you.

You probably know that every medical facility, such as a hospital, needs a professional to do the medical billing and coding for insurance companies and patient invoices. Note that office managers or doctors might perform these tasks and duties in addition to their main responsibilities, or they can hire one or several staff members in order to better handle these duties.

And it is worth noting that as clinical workers are often focused on patient care, in many cases, it usually falls to trained and experienced specialists to manage the essential administrative work of medical billing to help ensure that a healthcare provider is reimbursed for its services.

What is a Medical Billing Specialist?

Note that medical billing specialists are professionals who submit and audit financial claims in the medical and healthcare industry. You may know that medical billing specialists communicate with medical professionals, patients, and insurance companies. The aim is to help manage the financial aspects of health care, ensuring that the medical bill gets paid on time.

Job Description

Medical billing specialists translate healthcare services into medical claims. These claims are submitted to relevant insurance companies. Note that medical billers have to follow up on the medical claims in order to ensure that healthcare providers get paid and run a profitable practice.

There is no doubt that the medical billing process is very important to the overall financial health of your practice. This is because if medical claims aren’t submitted promptly, then the doctors and other staff would not get paid.

Responsibilities and Duties of a Medical Billing Specialist

Keep in mind that the job duties and responsibilities of any medical billing specialist may vary considerably depending on whether they work exclusively on medical billing or also work as a professional medical coder. And a medical billing specialist usually has the following duties.

  • Contact insurance organizations or patients in order to follow up on medical bills
  • Fully understand and explain the way medical insurance works
  • Regularly communicate with patients in order to obtain insurance information
  • Walk patients through various financial options and choices
  • Follow up on any unpaid medical claims within the standard medical billing cycle
  • Review payment information and records
  • Call insurance companies about any discrepancy or issues in payments if needed
  • Check each insurance payment for both accuracy as well as compliance with contract discount
  • Research and appeal denied medical claims
  • Answer all insurance and patient inquiries relating to assigned accounts
  • Set up various patient payment plans
  • Update billing software with any rate changes
  •  Work collection accounts
  • Use specialized software for submitting insurance claims
  • Review patient information and records and reliably code them
  • Maintain patient confidentiality
  • Understand as well as use ICD-11
  • Be aware of various changes in the insurance industry

Medical Billing Process

You may have heard of the medical billing process. Note that it is a series of steps that billing specialists complete in order to ensure that medical professionals, such as doctors, are reimbursed for their services. A good and competent medical billing specialist knows and understands how to get their healthcare provider paid promptly for the various services they render, minimizing rejected or denied medical claims.

Keep in mind that depending on the circumstances, the billing process can take just a couple of days to complete, or it might stretch over many weeks or even months. Although the billing process might differ slightly between different organizations and medical offices, here’s a standard outline of a typical medical billing workflow.

Registration of Patients

As you can imagine, patient registration is usually the first step on a medical billing flow chart. Note that every patient has to provide personal and health insurance information or details to their healthcare provider.  

After these insurance details are entered into the system, note that the patient won’t have to go through the same process again every time that they revisit the provider. 

This step involves collecting all basic demographic data on a patient, such as a name, age, date of birth, and the reason for the visit. Note that insurance information is also collected, which includes the name of the insurance company and the policy number of the patient. This information is verified by a medical biller. Professionals use this information to set up a patient file, which is referred to during the whole billing process.

Determination of Financial Responsibility

The next step in the medical billing process is to determine the financial responsibility for the medical visit. Note that this means going through the patient’s insurance details in order to figure out which procedures and medical services to be offered during the visit are covered.

If you get all the details needed for patient registration and obtain information regarding the patient’s reason for the visit, you can determine if the insurance provider will cover the medical bill or not. On the other hand, if there are some procedures or medical services that insurance will not cover, the patient is informed that they will be personally responsible for all those costs.

Medical Coding of Diagnosis, Medical Procedures, and Modifiers

You may know that the correct and accurate coding of medical claims is important for informing the insurance provider about what a patient is being treated for and the specific treatment method the patient is undergoing.

This is why it is crucial to use the correct diagnosis codes in order to describe the patient’s symptoms and illness as well as the correct procedure codes for describing the patient’s treatment method. Note that the insurance company can only make a reliable assessment if they have all the correct codes as well as modifiers.

Preparation of the Insurance Claim

The next and important step in the medical billing process is to prepare the insurance claim. During this step, the medical biller will enter the details of the medical bill in a suitable format required by the insurance payer. Keep in mind that once the medical biller has prepared the claim, they are responsible for ensuring that this claim meets the compliance standards.

And the biller has to be careful when completing the claim form with reliability and accuracy to include all of the details required for the claim to be timely approved.

Claim Submission

After the claim has been adequately completed, it has to be submitted to the relevant insurance company for payment. It is worth noting that HIPAA compliant healthcare organizations in the US have to submit these insurance claims electronically. This is great as it reduces the risk of errors caused by manual submissions. 

Medical billing specialists need to have access to all the information about the insurance provider as there are a lot of variables that each insurance payer uses to determine when and how to submit a claim.

Monitor Claim Adjudication

Did you know that adjudication is the comprehensive process by which most payers evaluate and assess medical claims and then determine whether these claims are valid and compliant? If they are valid, a determination is made of the amount of reimbursement that will be received. Keep in mind that during this process, a claim can be accepted, denied, or rejected. And an accepted medical claim will be paid as per the insurer’s agreements with the healthcare provider.

Denial Management

Medical billing specialists will also review any denied claims. And note that if they find that the medical claim accurately and reliably reports all procedures and services, they will proceed and appeal to the payer to review the claim. And it is worth noting that plenty of scrutinies usually goes into the decision to enter an appeal depending upon the sum of money.

Sometimes, medical billers might not appeal. This is especially true if the appeal process may involve more resources compared to the amount of money that is claimed.

Preparation of Patient Statement

Once the medical claim has been duly processed, you have to bill the patient for any outstanding charges. Note that the statement usually includes a detailed and comprehensive list of all the procedures and services rendered, their total costs, the amount the insurance company paid, and the total amount due from the patient. After the payment for the claim is received from the insurance provider, the patient pays the outstanding amount.

Follow up on Patient Payments

This step in the billing process ensures that the bills are paid. Medical billers have the responsibility of mailing out accurate and timely medical bills. They also have to follow up with all patients whose medical bills are delinquent. Also, once a medical bill is paid, the information is timely stored with the patient’s file.


Finally, a billing team is also required to prepare extensive and detailed reports. These reports help the practice enhance and streamline its medical billing practices. Note that these reports also help identify any wrongly filed claims, monitor trends in medical claim denials as well as rejections, and help the billing team in improving their efficiency.

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