I've been in the revenue cycle/medical billing field for nearly 40 years. I've been in leadership or consulting for most of those years. I feel this gives me pretty good perspectives on how things should work.

Ed's Retirement Party : March 17, 2010 - 1133
Parker Knight via

There's no doubt that every year there are some kinds of changes because of insurance and/or technology. With that said, I can honestly tell you that the problem I see is that many medical billers don't do or know the things that never change all that well.

I see way more bad billing processes and billers than I do good; that's problematic from where I sit. Health care is in financial trouble across the board, especially hospitals. Not having people who are trained well or know a lot of the things they should know to get claims paid hurts them. What hurts even more is that often leadership doesn't know enough to address these things; the blind leading the blind unfortunately.

I've been on both sides of this; I was a biller, then a supervisor and then a director, years before I became a consultant. I'm here to help.

Below are 6 things that every medical biller needs to know and learn to be proficient and knowledgeable about. It will not only make you a superstar, but could lead you towards management, independent consulting, and other heights down the line. In this regard, there are a few differences between hospital billing, physician billing and clinic billing, but most of what's below should apply to everyone. This isn't in depth information, but it's a pretty good start.

1. The meaning of denials

This is one of the biggest issues, and the major reason it takes a long time for claims to get paid. Instead of understanding the reason a claim is denied, I've seen billers immediately send out the same claim with no changes, either thinking it'll get paid the next time or just to get it off their claims list. If you don't know what the denials mean, you're just wasting time.

2. Procedure codes

Also known as CPT-4 or HCPCS codes (we'll come back to HCPCS in a bit), there's at least one of these on every single claim that goes out. Many times you'll see a denial message that says "procedure doesn't match diagnosis" or something else related. You also might get a denial saying it's a non covered service. If you don't know what these codes are and how to find out what they mean, you'll never be able to correct the claim.

3. Diagnosis codes

Once again, there's at least one of these on every single claim that goes out. Sometimes you'll get the same denial as above to match up with a procedure code. This is also known as ICD-10, and it's a bit more complicated than it used to be so you'll probably have to talk to someone in medical records for confirmation if you see the above denial, unless you're lucky enough to have a manual in your office (which you probably won't). However, on this one you're just as likely to get a denial saying you either needed an authorization or it's a non covered diagnosis.

4. Every claim needs a procedure code, but not all HCPCS codes are procedures

All CPT-4 codes are considered procedure codes, even if they're only E&M (evaluation & management) codes. HCPCS codes can be procedures, supplies, pharmaceuticals and a few other things. If the only code on a bill is a supply code the bill won't be paid. Depending on the insurance it's possible that a bill with only a pharmaceutical on it won't be paid either. Therefore, it pays to get used to looking at a HCPCS manual to be able to look these things up; this you should have in your department, and if you don't your director or supervisor doesn't know how to do their job.

5. Phone skills in talking to insurance companies

I see this as a major failure in a lot of places; sometimes billing people don't even know they're supposed to do this (goodness, in one place they weren't allowed to do this; what a mess!). You need to develop good phone skills, which includes a process of questions, to get your answers as fast and detailed as possible.

The first question is always a statement: "I'm calling to find out the status of a claim", or some derivative of that. Quite often this is all you'll need to find out why a claim hasn't been paid. If you know how to correct things after getting that information you're good; if not, you need to learn how to ask follow up questions while you're still on the phone with that person. Having to call back not only wastes time, but you might not get the same person you spoke to the first time. If you're lucky, you'll get used to talking to a specific person most of the time you call; it could be the most valuable relationship you ever have.

Another important thing here; always try to research a claim on your own before calling an insurance company with questions. If they think you don't know what you're talking about, they may not be as helpful as they'll be if they think you've got skills; that's just human nature.

6. Phone skills in talking to patients and family members

There are always two things to remember here. One, you can't use your normal jargon and terminology with them because they're not going to know what you mean. Two, you have to be discerning when it comes to discussing certain things over the phone.

Talking money is one thing; talking codes, unless they show an aptitude for that type of thing, might be another. You also have to know your states privacy laws of disclosure as it pertains to minors or items of a sexual nature. Remember to be courteous and not condescending; when all is said and done, though they don't want to, these are the people who are actually paying you.