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Medical billing specialists are key players whose role goes beyond just coding and billing. They are a pivotal link in the healthcare chain and bridge the gap between healthcare providers, insurance companies, and patients. They ensure the financial health of the healthcare provider, assist with patient and long-term care resident financial matters, and act as a conduit in the ever-complex healthcare insurance web. 

Medical billing specialists—also known as medical coding specialists, medical billers, or medical coders—operate within the broader scope of medical records and health information technicians. According to the U.S. Bureau of Labor Statistics, the field has an expected growth rate of 7% from 2021 to 2031, which will result in an estimated 14,900 job openings.

While medical billing and coding are often grouped together, they are technically two separate job functions, each bearing its own responsibilities and tasks. In larger healthcare facilities, these roles might be divided into two distinct positions:

  • Medical coding specialists: This role involves converting a healthcare provider’s diagnostic and procedural notes into specific codes, which are utilized for record-keeping and insurance billing.
  • Medical billing specialists: Professionals in this role generate invoices and send the claims to patients’ and long-term care residents’ insurance providers based on these codes. They also identify co-pay requirements, track payments, and follow up on any outstanding payments from both insurance companies and patients.

Medical billing and coding specialists use standardized codes to enter a resident’s diagnoses and services into an electronic health record system. These codes indicate the reimbursement amount that the resident’s insurance provider passes onto the healthcare provider under the resident’s policy terms.

In more detailed terms, their daily tasks often include:

One of many medical billing specialists running the numbers for their long-term care facility.
Medical billing and coding specialists use standardized codes to enter resident diagnoses and services into an electronic health record system.
  • Medical coding: They translate healthcare services, procedures, medical diagnoses, and treatments into universal medical alphanumeric codes. This is essential for maintaining uniformity and avoiding confusion when working with different healthcare providers and insurance companies.
  • Billing: Once the medical procedures have been coded, they create and send out invoices to patients or their insurance companies.
  • Follow-ups and collections: After billing, they also follow up on unpaid bills, which may involve contacting patients, answering their queries about the bill, and negotiating payment plans if necessary.
  • Insurance claim processing: They prepare and submit insurance claims and deal with any issues or disputes that may arise with insurance companies.
  • Record keeping and data management: They maintain patient billing records and ensure that they are accurate and up-to-date.

In the next section, we will look at outsourced medical billing specialists and their impact on the healthcare space.

The Rising Need for Outsourced Medical Billing

The medical billing sector has been witnessing a transformation, particularly in the area of outsourcing. Recent data on outsourced medical billing projects the market for outsourced medical billing specialists to grow from $13,842.19 million in 2023 to a staggering $23,709.28 million by 2028. This represents a Compound Annual Growth Rate (CAGR) of 11.36% during the forecast period of 2023-2028.

An unexpected catalyst in this growth trajectory was the COVID-19 pandemic, which significantly accelerated digital development within healthcare systems. As the pandemic swept across the globe, businesses increasingly turned to digitization, opting to outsource non-core aspects, such as billing and accounts. This digital shift is expected to contribute positively to market growth.

Further, the pandemic spurred a trend toward digital billing. There has been a marked increase in consumer interest in online billing payments since the pandemic began, fueling the demand for medical billing outsourcing. This trend is made clear in a Healthcare Payments Insight Survey Report conducted by Elavon, which revealed that consumers who utilized emerging payment methods demonstrated high satisfaction rates in settling their medical bills.

The relentless pressure of the pandemic on global healthcare systems made it necessary for medical facilities to ensure efficient processing and storage of billing data. This led to the increased outsourcing of these functions, driving market growth further.

Other factors propelling the medical billing outsourcing market forward are: 

A frustrated nursing home controller trying to work without outsourced medical billing services.
Outsourcing medical billing to a specialized service provider can help ensure compliance with billing and coding regulations.
  • An emphasis on compliance and risk management: Outsourcing medical billing to a specialized service provider can help ensure compliance with billing and coding regulations, as these firms are experts in navigating the ever-evolving regulatory landscape. They possess in-depth knowledge about changes in billing rules, coding updates, and payor requirements, thereby reducing the risk of billing errors and consequent penalties.
  • The pressing need for efficiency: Errors in medical billing can lead to claim denials, delayed payments, and reduced revenue. By outsourcing medical billing, healthcare providers can benefit from the expertise of dedicated professionals who can streamline the process, minimize errors, and ensure the timely submission of claims.
  • Reducing in-house processing costs:  In-house medical billing can be expensive, as it involves hiring and training staff, purchasing and maintaining billing software, and managing the continuous cycle of receivables. Outsourcing medical billing will significantly reduce these costs, meaning providers can save on direct expenses such as salaries, benefits, and operational costs associated with an in-house team.

In essence, the need for compliance, efficiency, and cost savings are collectively fueling the remarkable growth of the medical billing outsourcing market, which will continue for the next decade or so.

So what are the positive impacts of outsourcing medical billing?

  1. Improved cash flow: Medical billing experts that claims are submitted accurately and on time, thereby reducing the chances of claim denials and delays, resulting in faster reimbursements. By keeping the cash flow steady, practices can avoid financial strain and concentrate on patient care.
  2. Reduced administrative burdens: This means your team can focus more on critical tasks, such as patient care, which can ultimately enhance staff productivity and job satisfaction.
  3. Improved revenue optimization: Medical billing experts identify and rectify billing errors, spot missed charges, and flag underpayments. Their expertise can substantially increase an organization’s profitability.
  4. Greater precision and punctuality: By minimizing errors, these experts significantly reduce the likelihood of claim denials and delays, and this leads to more prompt reimbursements.
  5. The opportunity to focus on resident care: With the burden of administrative tasks reduced, long-term care providers can dedicate more time to what they do best, providing quality resident care. This leads to improved resident satisfaction and can positively impact a facility’s reputation.
  6. Reduced costs: Medical billing outsourcing eliminates the need to invest in expensive software, hardware, and employee training related to billing, translating into considerable savings.
  7. Enhanced revenue cycle management: Medical billing companies employ experienced professionals well-versed in medical billing and coding, and their expertise ensures accurate coding, timely billing, and diligent follow-ups on claim denials.
  8. Better access to the latest technology: Medical billing companies continually invest in the latest technology and software to improve the efficiency of their services. By outsourcing, practices can leverage this advanced technology and benefit from their expertise without making the investment themselves.
  9. Reduced errors: By ensuring accurate coding, proper documentation, and timely claims submission, the chances of claim rejections decrease significantly.

Contact us here to explore cutting-edge nursing home financial software to empower your medical billing processes.

Outsourced Billing Experts: the Skills and Expertise Required

By now, it’s clear that outsourced billing experts play a critical role in healthcare operations. However, these medical billing specialists need a particular set of skills and must fulfill certain requirements to perform the job effectively.  For those interested in medical billing specialist jobs, there are certain key skills they will need to gain: 

An outsourced billing expert providing advice to a nursing home administrator.
Outsourced medical billing experts must have a strong understanding of ICD codes, which are assigned to every diagnosis and procedure.
  • A strong understanding of ICD codes: Outsourced medical billing experts must have a strong understanding of the International Classification of Diseases (ICD) codes, which are assigned to every diagnosis and procedure. Specialists need to apply them accurately to ensure correct billing.
  • Competency with computer software: Medical billing specialists must be well-versed in using spreadsheet/workbook software, accounting software, and ICD code databases. They should be comfortable navigating these systems to input and extract the necessary data.
  • Insurance knowledge: The best medical billing companies should have a working knowledge of how health insurance companies operate. Doing so improves communication between these companies and allows the specialist to correct or adjust statements when necessary.
  • Basic bookkeeping skills: Medical billing and coding also demand basic bookkeeping skills, like simple accounting math for tracking the cost of a service and balancing it against the amount that the healthcare facility had to pay to provide it.
  • Customer service skills: Medical billing involves interaction with both patients and insurance companies. Excellent customer service skills help make the billing process flow smoothly, enhancing patient satisfaction and facilitating dealings with insurance companies.
  • Attention to detail: Accuracy is paramount in medical billing and coding. Keen attention to detail helps reduce potential mistakes and contribute to better job performance.
  • Clear communication skills: The specialist must be strong in both spoken and written communication.
  • Time management: Knowing how to prioritize tasks, balance workload, and manage time effectively is crucial for this role. It helps in increasing productivity and ensuring timely completion of tasks.
  • Organization: Medical billing specialists often have to track multiple procedures and patients simultaneously. So exceptional organizational skills can help reduce the potential for errors and alleviate stress during busy periods.
  • Conflict management: Sometimes, medical billers may need to deal with non-paying patients or insurance companies. Using conflict management skills and emotional regulation in tense and stressful situations will lead to better outcomes.

So how does one become a medical billing specialist? By going through these steps: 

  1. Determine if medical billing is a good fit: Evaluate if your personality and skillset align with the requirements of the profession.
  2. Choose a training program: Training programs can last from four to eight months, depending on your prior knowledge and experience in healthcare.
  3. Fulfill CPB essentials and education requirements: Develop an understanding of medical insurance, claim forms, billing regulations, and the ability to read and analyze medical records. You will also need to study anatomy, pathophysiology, and medical terminology.
  4. Study for the CPB exam: Prepare for the Certified Professional Biller (CPB) exam using study guides, practice exams, and educational resources.
  5. Take the CPB certification exam: Schedule and pass your CPB certification exam in order to earn your professional title.
  6. Network with peers: Engage with industry peers by way of professional associations, conferences, seminars, and online forums. This will build your network and help you gain industry insights.
  7. Get your first medical billing job: Start your job search using your newly gained certification and connections. Look for opportunities in hospitals, clinics, health insurance companies, and billing outsourcing firms.

Medical Billing Specialists: Pros and Cons of the Job

Through our journey into the world of medical billing specialists, we’ve discovered the profound impact these professionals have on healthcare.  We’ve also looked at the skills one needs to become a billing specialist, and the necessary steps to get their certification. 

For those considering taking on this role, it is worth mentioning that it comes with its unique sets of advantages and challenges. Some of the negatives you might encounter on your path to becoming a medical billing specialist include: 

  • Education and training requirements: Entry into this profession requires a high school diploma or GED as well as the completion of an accredited training program. Additionally, you will need to obtain certification, which needs to be renewed every two to three years and will involve additional effort and expenses.
  • Constant learning: The medical billing and coding profession demands you to learn a myriad of new codes and stay updated on any recent changes in the industry.
  • Computer proficiency: Proficiency in using a computer is essential, and the job could potentially lead to health issues, such as carpal tunnel syndrome, due to repetitive keyboard use.
  • Sedentary nature of work: The work mostly involves sitting for extended periods, which might not be suitable for everyone.
  • Salary and interactions: An entry-level salary in this profession might not be as lucrative as some might hope for, as the person could earn around $21 per hour. Also, the job requires constant interaction with third parties, like insurance providers, which can be taxing for some.
  • Stress and loneliness: The nature of the job can be stressful, especially when dealing with complex cases. And if you choose to work remotely, it might get lonely without the company of colleagues.

It’s not all negative, though. The positives significantly outweigh the negatives, and they include: 

  • Less time in school: Unlike many healthcare careers, becoming a medical biller and coder does not require several years of college education.
  • Affordable and accessible training: The training can be completed online at a cost significantly lower than other professions.
  • Opportunities for growth: There is substantial room for advancement and salary increases for a medical billing specialist. One can choose to work for a wide range of healthcare facilities—from single practices to multi-facility organizations—and as they gain experience, they can even take on consultancy roles. 
  • Work environment flexibility: The profession allows you to work from home or as an independent contractor or in other settings, from hospitals to clinics to insurance offices.
  • High demand: As healthcare systems grow more complex, the demand for medical billers and coders is on the rise, which means you will have job security.
  • Geographical flexibility: The ability to work remotely also means you can work from virtually anywhere.
  • Earning potential: Although the entry-level salary may not be high, with experience and further refinement of your skills, you can earn a high income.
  • Flexible schedule: Depending on your employer or if you’re self-employed, you may have the option to choose your own hours.
  • Job perks: The profession comes with some attractive job perks like healthcare benefits, retirement plans, and more, depending on the employer.

Ultimately, it’s all about weighing these pros and cons and deciding what aligns best with your personal goals and lifestyle.

For more on recent trends in long-term care, read our blog and subscribe to the LTC Heroes podcast.