A medical billing and coding certification is one of the integral aspects of the healthcare and financial industries. It is the one document authorizing medical coders and billers all over the country to do their work, and in effect guaranteeing their competence to service medical patients, health service providers, health and related insurance companies, and other concerned parties. Without these thousands of medical coders and billers, the entire system which ensures that health-insured Americans receive the medical service they pay for may slow down, if not grind to a halt.
To understand the value of a medical billing and coding certification, we must first take an overview of the health care industry which also includes insurance companies. Many Americans today receive medical care because they pay regularly for the policies that they signed on from insurance companies. A health insurance policy may cover a wide range of illnesses and health conditions, and their respective treatments. But each policy depends on the choices that the patients have made when it comes to the health conditions they want to be insured for.
For example, John, a 25-year-old single IT web developer, may only choose to get a general health policy that covers the usual flu, cough and colds, migraines, a cardiovascular check-up, and accident-related injuries. His choices depended on his lifestyle; John still believes he is healthy enough to withstand any illness but he knows he can’t foresee an accident from happening. At the same time, the stress on the job makes him want to watch out for his blood pressure levels.
Contrast this with Deborah, a 40-year-old college professor who is a single mother taking care of a teenage daughter. A health policy is her protection against protracted illness which can lead to a possible loss of income, which she wants to avoid at all costs because of her responsibility for her child. Deborah takes a policy that covers several health conditions that set on women who are approaching the 50-year mark. Aside from the general illnesses covered, her policy covers cardiovascular conditions, osteoporosis, mammogram and other breast check-ups, and gynecological tests.
John and Deborah have different lifestyles which affect their health and which in turn influence their choices of health coverage. But they do share one advantage: should they incur an illness or an injury in the health areas covered by their policy, they do not have to shoulder all the costs. Their health insurance company does all the necessary payment to the health service providers like the hospitals, clinics, and doctors they visited or consulted with.
Essentially, their health insurance saves them significant sums while assuring them of health service that presumably cushions them against the consequences of any illness they had covered. It also allows them to continue living and enjoying their preferred lifestyle.
Medical Coders and Billers: the Profession
This system cannot continue or at the very least function efficiently without one particular set of professionals: medical coders and billers. These unsung heroes of the health and insurance industries are responsible for making sure that the health insurance companies pay the health service providers and thus assure continuity of service to the medical-patients-cum-policy-holders.
Their tasks are far from simple but involve a complex process from the time the patient consults with his health service provider, informs his health insurance, and then finishes his consultation and any treatment; depending on the nature of the condition, this process can take as short as a week or as long as six months, or even years.
First, the medical coders and billers scrutinize the records of both health service providers and patients to verify the agreements made in the policy are consistent with the consultations that are being done. Then, they compute the billings incurred, double-check the claims made by the patient and his health service provider, and see to it that the payments are accurate and punctual. They handle documents such as claims submission and accounts receivable.
Sometimes, they also function as customer relations managers, holding the hand of the policy holder, patiently answering their questions, clarifying their issues, and communicating their concerns to the health service providers.
A distinction must also be made between the medical biller and the medical coder. These two are not identical but work in tandem. The medical biller is the one who personally deals with the patients and the health service providers, studies the claims, and manages the payment process.
The medical coder is the one that studies the codes that are present in every transaction. He sees to it that each document, invoice, and every other written requirement are precise, and are placed in their respective categories during this whole process. He is librarian and classifier in one. Without his oversight, the process can become chaotic.
Acting as one team, medical coders and billers working through the process see to it that every claim made must be verified and valid, and every act of service must be efficient, smooth, and non-disruptive. An inaccurate claim, a wrong signature, or an overbilling can result in a complaint which can stop the service to the policy holder, and might result in non-payment to the insurance company.
Medical billers and coders can be found in a variety of workplaces. The first environment they would gravitate to would be hospitals, clinics, offices of medical doctors, nursing homes, rehabilitation centers, and companies that do billing and consulting work. They can work in both the private and public sectors; federal governments employ medical coders and billers to work on Medicard claims. Although many employers require fulltime work, some contract medical billers and coders on a part-time or flexi-time basis.
Medical billers and encoders who have sufficient experience and a wide network of clients can actually put up their own company or consulting service.
The Need for a Medical Coding and Billing Certification
There was a time that a high school diploma was enough to get one employed as a medical coder and biller. But the evolving needs of the health and financial industries, including a restructuring of systems and a knowledge and appreciation of math, law and medicine, are making a medical coding and billing certification a must. Employers are increasingly asking for a medical coding and billing certification from their applicants.
For example, a medical coding and billing certification establishes that the professional who has it is familiar with the foundations of medical examinations such as diagnosis, medical procedures, and hospital codes. He is also versed in medical terminology, while a high school graduate may not.
It also certifies that the holder of the certification is acquainted with the laws, rules, and regulations that govern the healthcare industry. These include but are not limited to the Affordable Care Act (ACA), and the Fair Debt Collection Act, the False Claims Act, the Health Insurance Portability and Accountability Act (HIPAA), and the Stark Laws.
To get a medical coding and billing certification, the professional must receive formal training and education from a licensed school or training center. A course can be finished in a few months. Some educational institutions offer online courses along with the traditional classroom set-up.
The following details the various phases by which a student can enter and finish a course, and then fulfill the exam to get a certification.
First, he must choose which of the two categories of the profession that he wants to be certified in: a Certified Medical Reimbursement Specialist (CMRS), which is certified by the AMBA and requires a $325 fee; or a Certified Medical Billing Specialist (CMBS) which is certified by the MAB and requires a $199 fee.
Once he has finished the course, he must take the exam offered by either an accredited coding and billing professional association like the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).
The exams of both certifications cover the following subjects, which any certified medical biller is expected to excel in: anatomy and physiology, avoidance of accusations of fraud or abuse, managing denials and appeals, maintaining regulatory compliance, medical coding, medical terminology, and Medicare and private insurance claim processing guidelines.
Those who take the CMRS exam can find help from the Medical Association of Billers (MBA) website which has a study guide. The website also offers an online exam that will take 45 days to finish. The scores are sent to the student a few days after finishing the exam, while the confirmation of certification takes another three to five business days.
Those who want to take the CMBS exam have several options: a six-week online course that is flexible and can be taken at their own pace; a one-weekend course that ends with the certification test; and preparatory courses that will help them take the exam.
Some organizations offer courses that prepare the student before taking the exams like the AAPC and MAB.. Another is the American Medical Billing Association (AMBA).
Continuing Education for the Medical Billing and Coding Certification
The demand for medical coders and billers is growing: The Bureau of Labor Statistics estimates an 11 percent increase in employment from the present up to 2022. Certified medical billers earn an average of $34,000 – $35,000 a year.
The medical coding and billing profession has also become attractive to many seeking work for many reasons. First, any professional from any industry can transition to it, as long as he studies the courses, passes the exams, and gets the certification. Second, as explained above, it only takes a few weeks or a month to get certified; afterwards, he can be working in the industry within a year. Third, while it will get him entry to a valuable industry like the healthcare industry, it does not truly require working in an environment where he has to actually help in providing direct medical service. Fourth, it is appealing to those who are good with detail, and thrive in an organization that has a clear and set structure.
The competitiveness in the industries and the high standards required from their practitioners make continuing education a near imperative. Medical coders and billers with a CMRS certification must earn 15 continuing education units a year, while those with a CMBS certification must get 12 per annum.
There are several avenues where medical billers can update themselves and upgrade their certifications: online courses, professional development programs, or actual classroom sessions in accredited schools.
Like all worthwhile professions, the medical billing and coding job requires excellence on the job, commitment to the work, and an openness to continuing education. Laws about the healthcare industry develop over time, and medical technologies are enhanced or modified because of the non-stop innovation going on in the medical field. Facility for numbers and a meticulousness to detail are also desired attributes that will help keep the medical coder and biller keep up with the fast pace. It does require an investment in learning and certification, but the rewards are more than worth it.