A medical practice is more than just seeing patients. It is a business, and like all businesses, it has monthly bills to pay, and employees who want their paychecks. There are many different aspects to medical practices across the country.

A medical practice relies heavily on reimbursements from insurance companies to fulfill their financial obligations. However, filling out insurance claims for hundreds of patients each week can be very time consuming. The whole process can be a very frustrating experience.

A physician must either hire someone to perform this task, another expense that can be eliminated, or do it him or herself. Either way, it can be a grueling experience for the person filling out the forms. Often, filing the forms is another headache that can leave the person feeling a huge amount of stress.

If the forms are not filled out properly, the insurance company will reject them and the whole process is started all over again and often these claims are added to the stack of claims that are pending. This can cause financial hardships for many practices, especially small ones. Even when the claim is accepted, it can take several weeks or months for the insurance company to send the reimbursement check.

Many medical practices have found that by using a medical billing company, they have increased the efficiency in their office. The staff can concentrate on other areas of office work. Medical billing services have fast and secure methods of submitting claims to insurance companies electronically. This means that the claims are no longer lost in the mail or sitting in a stack on someone's desk waiting to be put into the system.

When a claim is filed electronically, it is either accepted or rejected immediately. The billing service then will make the necessary changes and re-submit the claim. Because the claim is accepted electronically, payment is sent within days instead of weeks or months.

Another benefit to using this type of company is that the personnel are highly trained in all aspect of medical billing. They are familiar with all of the rules and regulations and when they are updated or changed.

The medical billing service will also track each of the payments to make sure that the transaction is completed and that a check was sent. They will contact the insurance company and follow up on each claim that is not processed.

This gives physicians the time they need to treat more patients and to concentrate on them and not worry about when they will receive their payments.

Any type of medical facility can use medical billing services. It does not matter how big or small, the benefits are the same for all.

Many physicians are skeptical about using this type of service, especially small ones, however, the benefits of these services far outweighs any fees that they may charge because the reimbursement time is quick and the success rate of submissions is over ninety percent. This makes it very cost efficient for any medical practice.


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Medical coding/ billing is today one of the ten fastest-growing allied health occupations. Health care insurers process over 5 billion claims for payment every year in the US. Therefore, Medicare and other health insurance programs have to make sure that that all claims are processed without mistakes and so this requires a standardized coding system. Medical coding and billing professionals are responsible for submitting the proper documents to the various insurance companies and federal agencies for reimbursement of the medical expenses. Medical coders use special codes to specifically identify outpatient and also inpatient procedures / services and this is very useful for billing of both private as well as public insurance companies.

HCPCS stands for Healthcare Common Procedure Coding System. It is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). Established in the year 1978, HCPCS provides a standardized coding system for describing the specific items and services provided in the delivery of health care. This type of coding ensures that insurance claims are processed properly and is needed by Medicare, Medicaid, and other health insurance programs.

HCPCS codes exist in two levels.

* Level I is numerical and consists of the American Medical Association's Current Procedural Terminology (CPT)
* Level II codes are alphanumeric and meant for non-physician health services.

It is very essential for medical coders to keep in touch with the latest codes and changes. This is possible by the use of HCPCS books that contain the complete lists of HCPCS Level II codes with descriptions and guide the medical coder through current modifiers, code changes, additions and deletions.



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Ever wonder why sometimes when you get reimbursed for a claim, the insurance company has "changed the code to a more appropriate code for payment"? You submitted the claim as a 99214 but they paid you for a 99213 or even worse, a 99212. This practice is called downcoding.

Do you have to accept it? Well in some cases you do. A lot will depend on the contract that you have with the insurance carrier. Some contracts will only allow providers to bill certain cpt codes. In that case, they can change a billed code to one of the allowed codes. Or the contract may specify that you can only bill a certain number, or percentage of claims at the higher codes.

But sometimes an insurance carrier will just downcode your claim and it is not due to contract specifications. In that case you can appeal it. We recently had a claim that the insurance carrier downcoded a 99214 to a 99213 and told us that they only allow a provider to bill a 99214 every 6 weeks for a patient. That is ludicrous. How can that guideline apply to any patient?

Sometimes we just have to remind the insurance carriers that the doctors are the ones who determine the patient's needs. In this case we sent in office notes and a letter advising them that we were appealing the processing of the claim. The doctor had met the requirements to justify the billing of a 99214 and their "guidelines" were inappropriate. We received payment for the difference about 10 days later.

So if you are having problems with your claims being downcoded, and they are not due to contract specifications, you should appeal. Do not just accept what the insurance carrier does. That is what they are counting on. Just think of how much money they save on the providers that do not do anything about it.



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