Hire the best and most suitable medical claims billing administrator for your practice

Unpaid claims, denied claims, and rejected claims are the situation for every medical practice office. But there is a solution to all of these problems and headaches, and that is hiring the best and, in my opinion, the right Medical Claims Billing Manager for your practice. Please note that a Medical Claims Billing Manager is completely different from an Office Manager. His roles and responsibilities in each medical practice are completely different from each other.

Solid experience and knowledge in billing and coding are very important in choosing the right candidate. The candidate must have a high knowledge in the following:

1. Insurance and payer policies and guidelines (including knowing deductible, coinsurance, out-of-pocket costs, knowing the difference between out-of-network and in-network benefits/eligibility, all medical needs, rehabilitation services, home care services, etc.)
2. Extensive knowledge of different insurance plans (PPO, Managed Care, Open Access, HMO, Capitated, Medicare, Medicaid, National, Federal Employees Program, Out of State Plans, etc.)
3. Medicare and Medicaid Policies, Guidelines and Coverage Determination
4. Medical terminology (a background in anatomy and physiology would be great!)
5. Medical coding (CPT, ICD-9, HCPCS and use of CCI editions)
6. Using the Proper Medical Modifiers
7. HIPAA Compliance, Guidelines and Policies
8. OIG Recommendation for Compliance (Medical Practice Offices)
9. Fee Analysis, Contract Fees and Accreditation Process
10. Accurate, quality data and patient demographic information
11. Information System, Billing and Security of Patient Information

Now, consider the following job description when hiring the best and most suitable Medical Claims Billing Manager for your Practice:

1. Responsible for leading and directing the billing and collection efforts of the company. You must be highly analytical, experienced, educated, and knowledgeable.
2. Directs the general function of the Medical Billing Department:
1. Patient Benefits and Eligibility Verification
2. Ensure all signed forms (financial policy, new patient forms/insurance information, HIPAA and ABN for Medicare patients) are on file
3. Daily electronic submission of claims (paying attention to transmission receipts, rejected claims should be directed immediately to)
4. Maintains accurate patient demographic information and data on file
5. Reconcile charge/encounter forms with appointments
6. Patient statements (a soft collection would be great!)
7. Conduct an internal audit (a must if you want to comply with OIG recommendations!)
8. Maintains and updates the Internal Medical Billing Compliance Program (very important!)
3. Review and analyze tariff and contract rates and EOB (Explanation of Benefits)
4. Review and analyze new patient registration, billing, and collection productivity reports, including detail of accounts by type, coverage, and reasons for unbilled and/or old reports.
5. Aggressive appeals of rejected/denied claims due to lack of medical necessity, underpayments, and down-coding. (support medical necessity, pay attention to use of appropriate modifiers and obtain adequate reimbursement, pay attention to bilateral procedures, unbundling/bundling)
6. Coordinates directly with patient adjusters on workers’ compensation and no-fault cases
7. Review credit agreements, refunds, and account adjustments.
8. Primarily responsible for reviewing monthly, quarterly, and annual reports (Practice Analysis Report, Collection and Aging Reports)

Of course, knowing what you expect from a medical biller based on your practice’s specialty is also vital to your hiring process. Are you a multi-specialty practice? Are you a primary care physician? How many patients on average do you see in a day? Do you perform surgery in the office? Do you bill for medicines and supplies, technical and professional component of radiology? In addition to doctors, do you have PAs (physician assistants), NPs (nurse practitioners), and therapists (physical, occupational, and speech therapists)?

Billing managers come and go (sad to say!), but offering them the best deal, including medical benefits, can entice them to work for you, even longer. These are the people who can keep your practice in business. I think you have to compensate them well.

Your other option is to outsource your medical billing to billing service companies might also be a good idea, there are many good and reputable billing service companies out there, it’s up to you.

Good luck doc!