Unpaid claims, denied claims, and rejected claims are every medical practice office’s predicament. But there is a solution for all these problems and headaches, — and that is by hiring the best and I think, the right Medical Claims Billing Manager for your practice. Please be aware that a Medical Claims Billing Manager is completely different with that of an Office Manager. Their functions and responsibilities in every medical practice is completely different from the other.

Solid billing and coding experience and knowledge is very important in choosing the right candidate. The candidate must be highly knowledgeable on the following:

1. Insurances & Payors Policies and Guidelines (including knowing what deductible is, coinsurance, out of pocket, knowing the difference between an out-of-network and in-network benefits/eligibility, all medical necessity, rehabilitation services, home care services, etc.)
2. Vast knowledge about Different Insurance Plans (PPO, Managed Care, Open Access, HMOs, Capitated, Medicare, Medicaid, National, Federal Employees Program, Out of State Plans, etc)
3. Medicare and Medicaid Policies, Guidelines and Determination of Coverage
4. Medical Terminology (a background in Anatomy and Physiology would be great!)
5. Medical Coding (CPT, ICD-9, HCPCS and use of CCI Edits)
6. Use of the proper Medical Modifiers
7. HIPAA Compliancy, Guidelines and Policies
8. OIG’s Recommendation for Compliancy (Medical Practice Offices)
9. Fee schedule analysis, Contracting rates and Credentialing process
10. Accurate and Quality Data and Patients Demographic Information
11. Computer System, Billing and Patients’ Information Security

Now, consider the following job description in hiring the best and right Medical Claims Billing Manager for your Practice:

1. Responsible for leading and directing the company’s billing and collection efforts. Must be highly analytical, experienced, educated and knowledgeable
2. Directs the over-all function of the Medical Billing Department:
1. Patients’ benefits and eligibility verification
2. Assuring all signed forms (financial policy, new patients’ forms/insurance information, HIPAA and ABN for Medicare patients) are on file
3. Daily electronic submission of claims (paying attention to transmittal receipts, rejected claims must be immediately addressed to)
4. Maintains accurate patient’s demographic information and data on file
5. Reconcile charge/encounter forms with the appointments
6. Patient Statements (a soft collection would be great!)
7. Performs Internal Audit (a must if you are to complying with OIG’s recommendations!)
8. Maintains and updates Internal Medical Billing Compliancy Program (very important!)
3. Reviews and analyzes fee schedule and contracting rates and EOBs (Explanation of Benefits)
4. Reviews and analyzes new patients registration, billing and collection productivity reports, including detail of accounts by type, coverage and reasons for unbilled and/or aged reports
5. Aggressively appeals rejected/denied claims due to lack of medical necessity, underpayments and downcoding! (support medical necessity, paying attention with use of proper modifiers and get reimbursed properly, pay attention to bilateral procedures, unbundling/bundling)
6. Directly coordinates with the adjustors for patients on Workman’s Compensation & No-Fault Cases
7. Reviews credit arrangements, refunds, and adjustments on accounts
8. Primarily responsible for reviewing monthly reports, quarterly and yearly reports (practice analysis report, collection and aged reports)

Of course, knowing what you expect on a medical biller based on your practice 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 drugs and supplies, radiology technical and professional component? Other than the Medical Physicians, do you have PAs (Physician Assistants), NP (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 may attract them to work for you, even for a longer tenure. These are the people who can make your practice stay in business. I think they must be compensated well.

Your other option is, outsourcing your medical billing to billing service companies might also be a good idea, there are a lot of reputable and good billing service companies around, it’s your call.

Good luck Doc!