There Are People Other Than Doctors in Healthcare

One of the most rewarding careers is in health care, according to everyone on the planet. What many individuals don’t tell you is that you do not have to be a nurse or a doctor to have that rewarding career. I am a medical biller, coder, and auditor, and the love I have for my job is what has sustained me throughout the pandemic.

Being a medical biller, I have to work with the insurance companies as well as the families to make sure that procedures get paid appropriately and on time. A very good medical biller will establish consistent contacts that they will use everyday. I was fortunate enough to build that relationship with the local Veteran’s Affairs team, and some are also friends outside of my work. The majority of my time is spent reviewing insurance’s policies and payment schedules, and then applying them to the invoices. If there is a discrepancy with the schedule compared to a payment, typically a phone call is more than enough to find the solution. I also have to be able to communicate with families when they call with questions. Most of the time, individuals are understanding once situations are explained to them. There are the times when I have been yelled at, but those are few and far between as long as the company I am with maintains a consistent and transparent policy.

Most of the time, a medical biller is also a medical coder. Medical coding is the transformation of health care diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. What this means is that when a doctor diagnoses a patient with hypertension, and writes that into a patient’s chart, the medical coder reads the chart, transforms the hypertension into the alphanumeric code I10, and that I10 is entered onto a claim form that the medical biller submits to the insurance company for payment. While this is overly simplified, I find the process fascinating, because medical providers are not always consistent with what they write in a patient’s chart. As my career advanced, I found that I would have to query medical providers as to what they were writing, but also conduct research with coding manuals like ICD-10-CM, which the for diagnoses, and CPT, which is for procedures, to make sure the specificity of the codes were accurately conveyed to claim forms.

Finally, there is the medical auditor side of my job. Typically a medical auditor is a different person because this individual is reviewing the medical providers. A medical auditor gathers a number of claims that a provider performed, and uses a score sheet from the American Medical Association or Centers for Medicare and Medicaid Services, and reviews the written documentation to evaluate if the CPT code entered was accurately performed. Being a medical auditor is a double edged sword, because it is the auditor’s job to protect the company and the provider, but also the insurance companies. When a medical auditor finds a discrepancy that makes the CPT code different than the one submitted, they must meet with the provider and discuss the findings. Upon review, most providers will agree with the findings and a new claim will be submitted to the insurance as a correction. This could either result in money being returned to the insurance company or more money being sent to the provider’s company. Those reviews are what can make or break an auditor’s love for their job.

Overall what I found was that I enjoyed being an auditor more than a biller or coder. A biller and coder is the individual who makes sure the money continues to flow into a health care company. It is not the doctor who does the service, it is the biller. Hospitals would not have the money for equipment if the biller does not conduct their follow up claims. Physicians would not get paid their exorbitant salaries, if the biller did not make that phone call to the insurance company. It is also not the doctor who is submitting data to the insurance company and the census reports, it is the coder. For the pandemic, it was not the doctor who reported the amount of COVID cases, it was the coder. But it is an auditor who is communicating with the provider. It is the auditor who is telling the doctor, “you may be a doctor, but according to the established guidelines set by CMS and AMA, you are wrong with the code you used.” I firmly believe that individuals with higher power should be more closely monitored than those with less power. It is an established fact based on historical data that individuals who already have power will generally crave more. I feel that it is an auditor’s job to bring those individuals humble by having the difficult conversations. “You may be a doctor, but that doesn’t mean you are automatically right. Here’s why…”