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How to Collect Payments from Patients as a Medical Coding and Billing Associate

As a medical biller and coder you may be called upon to contact patients to collect payments due the provider. Yes, your most important job is to fully abstract all billable services and supporting medical necessity from the physician’s documentation. But the other part of your job is to follow provider-payer contracts that stipulate that the provider is obligated to collect patient balances. Failure to do so may result in the contracts being canceled.

The contract defines the conditions for submitting claims, the procedures to be submitted for payment and the medical necessity that supports the procedures, and reimbursement obligations of both the payer and the patient. When you try to collect payment from patients, you must follow the same principles of honesty and integrity that you follow when you code.

When you follow up on outstanding patient payments, be sure to do the following:

  • Treat all patients the same, regardless of what kind of insurance they have. Most offices implement a policy to address patient billing. Follow this policy consistently for all patients.

  • Document, document, document. Good documentation practices provide a paper trail that verifies your consistency. Most providers, for example, follow the “three billing cycle statements” rule: They bill patients at least three times before forgiving an outstanding balance. You should document each patient statement in the patient record along with any conversations with the patient or payer.

  • Know what the contract says. Payer contracts generally indicate how patient balances are to be handled. Medicare, for example, requires a collection effort for all Medicare patient balances, regardless of the amount. Others usually have similar expectations. If the provider fails to make collection efforts for patient balances, the insurance company may view this as breach of contract and terminate the agreement or deny renegotiation.

  • Be aware of the False Claims Act, which makes defrauding government programs a crime. You can run afoul of this act if you knowingly submit a false claim, cause a false claim to be submitted, or create a false record that results in a fraudulent claim. Billing 30 claims for a day that only shows 20 patients, for example, is a violation of the Act.

  • Know the boundaries of your claim. You can’t ask for money that isn’t coded. Pretty simple. Knowing what procedure you can code on any given claim is a vital part of doing your job ethically and accurately. You can find this information in the payer contracts, in the CPT book, and in other coding resources, such as professional publications. You can also ask more experienced coders in your office.

The cardinal rule of ethical coding is “When in doubt, ask.” If you find any ambiguity in the patient record, query the provider to get clarification. Any claim must be fully supported by the record.

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