Insurance companies employ medical billing and coding professionals to audit claims and make sure that covered procedures receive the proper amount of reimbursement. Often times the first person to uncover instances of billing fraud or abuse is a billing and coding professional working for an insurance company, who may also be referred to as a claims analyst.
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A competent billing and coding professional can prove to be invaluable to an insurance company. One of the most common reasons a claim is denied is because it is not covered according to the insurance policy. Billing and coding professionals can potentially save their client thousands if not millions of dollars by denying claims for a lack of coverage or other reason. Conversely, a sloppy billing and coding professional can be a costly liability.
Medical Billing and Coding for Insurance Companies – What to Expect
Working for a particular insurance company, the medical billing and coding professional will be very familiar with the coding used by his or her individual company. Insurance companies themselves may specialize in a niche area of health insurance, or may offer more general coverage. Either way the claims analyst will need to be familiar with exactly what treatments are and are not covered. In some cases the professional will need to become familiar with policies that go beyond healthcare coverage.
When an insurance company receives a claim, the billing and coding professional will start by confirming that the procedure performed is covered under the terms of the insurance policy and that the patient is properly enrolled. It will also be determined if pre-certification was authorized or needed for a claim, and if there was a medical necessity to perform the procedure.
Next the analyst will examine the codes assigned to the particular medical procedures to see if they are accurate. A patient’s personal health record may also be consulted to ensure the procedure coded for fits into the patient’s overall healthcare context. If the procedure is confirmed to be covered and everything else is in order, the billing and coding professional will issue a stamp of approval.
Preparing for Insurance Company Billing and Coding Careers
Insurance companies are looking for educated, skilled, and experienced billing and coding professionals. Depending on the company, it may be willing to train and hire a billing and coding professional with competitive credentials fresh from school with no previous experience.
Some educational institutions offer specialized certification and courses in the field of insurance company billing and coding. Having such a certification can be advantageous, as can having prior experience- if not as a claims analyst then at least in the field of billing and coding. Formal education in general as a medical billing and coder can also be beneficial.
Each insurance company will have its own idea of the qualities it is looking for in a billing and coding professional. Candidates are advised to research the hiring requirements for several appealing insurance companies early on in their educational process in order to determine the most strategic course of action.