Defining the Medical Biller's Role

I constantly come across questions from aspiring medical billers, many of them are new to this occupation, who post their questions in online forums for medical billers and coders. For example, someone recently asked in a very popular medical billing forum:

"I am French and I've been in the United States for a year. I intend to stay and find a good job. I am interested in the medical billing career but am wondering whether this is a field that hires foreigners. My plan is to enroll in a medical billing and coding program at a local community college in New Jersey but before I do so, I want to make sure that I will be able to get a job, being that I am not a United States citizen and speak with an accent."

How would you respond? Would you be able to help? Some questions are tricky, others are unrelated, others require an expert, someone who has been in the medical billing field as long as Steve Verno, a well known and respected certified medical biller and medical billing educational consultant and online forum adviser. Here is his response:

• You can be 18 and German, or you can be 65 and Polish, or 35 and French, medical billing is medical billing
• The process and training knows no age limit, nor nationality
• If you have the proper training, anyone can do medical billing
• Medical billing can be taught in Guam and practiced in Costa Rica
• My friend went to the Phillipines to teach medical billing
• I am 58, ugly and Hungarian American and I do medical billing
• I had open heart surgery and a stroke, but that hasn't stopped me
• You can do anything if you set your mind to it

Licensed professionals have limitations to what they can and cannot do. Doctors, nurses, EMTs, paramedics, barbers, manicurists and most professions have what is called a scope of practice. This is basically a line that is drawn to say you can do this, this, this, but not that, stay on your side within your scope of practice.

A pediatrician is a doctor that treats children, you don't see a pediatrician go to a beauty spa or hair salon giving massages and applying hair dye, as an example. You don't see EMTs performing appendectomys in the back of an ambulance. Medical billing is not a regulated profession and therefore there are no clearly defined limitations which is why so many people ask questions that have nothing to do with medical billing itself in the forums.

Many upcoming medical billing professionals wonder whether a medical biller is also a consultant. The best way to answer this is to explain what a consultant is. A consultant is a person who is a superior subject matter expert who can quote laws, rules and regulations; someone who can walk into a company and see what is wrong, or right immediately. A consultant knows where to find all the answers and is able to provide guidance with the appropriate supporting documentation. A consultant goes to a practice to help, this help can be guidance or getting your hands dirty. A consultant must always be right. A consultant is not self centered on making a name for themselves.

A consultant has the ability to say no so that it sounds like a yes. It takes years of experience to become a consultant. There are no classes to become a consultant. It takes years of experience as well as reading and reading and reading. Many of their responses are based on personal experience. A consultant has complete confidence and encourages the right way versus the wrong way to do things. Make a mistake and their reputation and credibility is ruined.

According to Steve, a medical biller is more of an adviser--rather than a consultant. A biller advises a provider on ways to improve billing and collections and lets the provider know about potential problems that may occur due to the lack of verified data to submit and get a claim paid. A medical biller does not advise on areas outside the scope of their training. As a biller, you provide services to your providers, who are your customers, but you do so within the scope of your practice, or the scope of our training only. For example, if you work as a biller for a dermatologist and are asked what the billing policy is for skin lesion removals for Aetna, then you can research this to provide an answer, since knowing health insurance carrier billing policies is within your scope of a medical biller.

On the other hand, if your doctor asks you for a legal opinion then this is outside the scope of your practice or training. If the doctor wants to know if balance billing an HMO patient is legal or not you can find the State HMO law and provide a copy to the provider, however you can not interpret what the law says because a medical biller does not interpret laws. As a biller, you need to know your State insurance laws, meaning have knowledge of it, however, you can't say it is illegal to balance bill an HMO patient. The provider can go to his lawyer for a legal opinion. The bottom line is simple: you must stay within the limits of what you were trained to do.

Medical billers have a simple task: billing. That means you send a claim to an insurance company, post payments, respond to outside information requests that relate to the claim, follow up on a claim with no response, communicate with the patient, or their insurance company about a claim that is denied, in review or pended, send statements to the patient and turn over delinquent accounts to the providers debt collection agency. Again, you stay within the boundaries of your training.

What medical billers are NOT:

• Managers of the provider's practice
• Lawyers
• Credentialing staff
• Contract Review staff
• Coders
• Physicians

When someone goes outside their scope of practice, which is basically outside the training that was received, then that someone opens the door to a possible lawsuit. Under normal circumstances, a medical biller has his/her hands full with verifying insurance information, data entry, claims denials, insurance company, attorney, and patient requests, AR recovery, filing, medical record requests, processing subpoenas, doing close day and close month procedures and reports, answering patient phone calls and other tasks required of a medical biller.

If you have too much time on your hands to do credentialing or contract negotiations, I suggest you run an insurance aging report and see how much money is still on your system that is over 60 days old. If you have just one claim, work on it to get it resolved. Stay safe by staying within YOUR scope of practice and the boundaries of your training.

Steve Verno and I, Danni R. go back many years, not only running and moderating the Medical Billing Community forum online, but more than anything, we have also become good friends. While I build websites where medical billers and coders find expert help, he assists medical practices with coding and billing advice and training, his specialties include Emergency Medicine, Family Practice, Urgent care, Pediatrics, and Internal Medicine. In his spare time he also is an active participant and adviser for several online medical billing forums, including the My Medical Billing Community.