Medical Billing Fundamentals

Medical billers are the ones responsible for submitting professional and medical claims to health insurance companies, hospitals, clinics, nursing homes, and other healthcare entities on time. If they work in a hospital, their tasks are far different from the others who are not working in the hospital.

Medical Billers

If you want to become a medical biller or if you just want to know more about medical billing, then here are the fundamentals about the process, major payers, and the know-hows of medical billing.

Fundamentals of Health Insurance Plans

Understanding the fundamentals of medical coverage plans allows a medical office personnel viably speak with patients in regards to their health care coverage benefits and talk about the patient’s account particulars with agents from the insurance company.

Having a fundamental knowledge of each kind of insurance will limit inconveniences for filing claims and gathering payments. To give you an idea, the two principal kinds of health insurance plans are Managed Care Plans and Indemnity Insurance, each catering to different and specific needs.

Programs of the Government

There are several health care programs of the government.


Always remember that Medicaid is not an insurer. It is a program that creates medical payments on account of the recipient. On the off chance that a third-party liability is present, at that point Medicaid is dependably the payor after all other options have run out. This essentially implies Medicaid pays last if other insurance is available.


Medicare is the government program that gives health care insurance to more than 40 million Americans including senior citizens of over 65 years old, permanently handicapped adults under 65 years old, and persons that live through End-Stage Renal Disease (ESRD) where the kidneys have failed and a person will require constant dialysis or transplant.


Tricare is a division of the Military Health System managed by the Department of Defense (DOD). It is the health care program for dynamic, resigned and Guard/Reserve service personnel and their families.


It is a little similar to TRICARE. However, CHAMPVA is handled by the Department of Veterans Affairs. If personnel is qualified for TRICARE, he or she can no longer qualify for CHAMPVA. Both TRICARE and CHAMPVA are only auxiliary to other health coverage plans which excludes supplemental plans and Medicaid.

The Process of Medical Billing

When a patient checks in, his or her demographic information is collected including the insurance payer, number of policy, and other information needed to process a claim free of errors. The provider will verify the member’s qualification every time a service has been rendered. The services are then charged and coded. The insurance payer will know about the illness or condition through coding of procedures, diagnosis, and modifiers. The claim is then checked for errors before being submitted. A plethora of information should be accessible by the medical billers in order to submit a claim adeptly. The payment is then posted which will also involve deposit functions and the settlement of posting proceedings with deposits.