In this Article
By: Anna Giorgi
Electronic health records (EHRs) are the primary means of managing clinical documentation, care coordination and revenue cycle management in contemporary healthcare. While clinicians use EHRs to document and monitor patient care, medical billers play a vital role in translating that documentation into the data needed for timely reimbursements.
In addition to a formal education in medical billing, medical billers need a combination of EHR proficiency and billing expertise to meet their professional responsibilities. From extracting clinical data from EHRs to submitting “clean claims” that are approved on the first pass, a medical biller is the bridge between the financial interests of healthcare providers, insurance companies and patients in a digital health record system.
The EHR in medical billing
Medical documentation is the foundation of the medical billing process. Information about the services provided to a patient, including tests, treatments and other care, is necessary to generate reimbursement from insurance companies and other payers such as Medicare and Medicaid. The quality and organization of clinical data in EHRs impacts billing accuracy and the prompt submission of claims.
EHRs with incomplete or incorrect information increase the rates of claim denials and delayed or lost payments, which ultimately impact healthcare services. Industry reports indicate that claim denials contribute to an average annual revenue loss of up to 5% of net patient revenue for hospitals, according to the American Health Information Management Association (AHIMA).
EHRs are necessary for accurate medical billing because they are the central source of data for the billing process. An EHR can include the following details:
- Demographics
- Progress notes
- Medications
- Vital signs
- Past medical history
- Immunizations
- Laboratory data
- Radiology reports
EHRs help medical billers connect clinical care with billing compliance and reduce claim denials. As digital medical records, EHRs enable better documentation, more accurate coding and a more efficient workflow, which can lead to improvements in the way services are billed and collected.
Research suggests that the adoption of EHRs from paper billing improves medical billing by reducing denials and decreasing the amount of lost revenue. The results were measurable in a study that reviewed the impact of EHR adoption on lost revenue in a large, integrated pediatric primary care network. The transition from paper-based patient records to EHRs in this network was associated with an increase of $11.09 in average per-patient charges and $11.49 in average per-patient collections.
Key responsibilities of a medical biller in navigating the EHR
Medical billers use EHR systems to retrieve the clinical, financial and administrative data needed to generate and submit accurate claims. To facilitate management of the patient revenue cycle, medical billers interact with EHRs in several ways.
Interpret and extract billable data
Medical billers must review provider documentation in the EHR to ensure that all diagnoses, treatments and services are appropriately recorded. Any mistakes or omissions may lead to underpayment or claim denials.
To make sure that all billable services are submitted for reimbursement, medical billers must know how to interpret progress notes, encounter forms and treatment plans. Cross-checking physician notes and procedure logs is critical for identifying missed charges and avoiding billing discrepancies.
Collaborate with coders and clinical staff
While medical coders frequently handle coding, medical billers collaborate closely with coders and providers to ensure codes match clinical documentation. Most EHR systems incorporate computer-assisted coding (CAC) features that recommend ICD-10, CPT and HCPCS codes. However, human oversight is still necessary to verify that codes are compliant, appropriate and supported by the medical record.
Generate and submit claims
After treatments are coded and documented, medical billers create and submit electronic claims using the EHR system, which is frequently connected with practice management software. The EHR system may incorporate clearinghouses and payer portals to expedite submission and lower manual error rates.
Medical billers must work precisely to ensure each claim meets the criteria of the specific system being used. With proactive steps to ensure accuracy, up to 90% of all denied claims are preventable, reports the Healthcare Financial Management Association (HFMA).
Manage denials and rework claims
Claim rejections and denials are inevitable in any healthcare setting. EHRs assist medical billers in monitoring the progress of claims, determining the reasons for rejections and resubmitting claims that have been corrected.
Using denial management tools integrated into EHRs, medical billers can speed up the rework process by sorting rejections by payer, denial reason or provider. Some EHR systems offer tracking features to detect patterns in denials and evaluate the underlying causes. This helps medical billers can take preventative measures to reduce recurrences by using EHR reporting tools.
Challenges of integrating the billing process into EHR software
Medical billing software automates the revenue cycle management process by establishing direct connections with practice management software and EHR systems. This integration ideally facilitates smooth data exchange for patient registration, insurance verification, accurate coding, electronic claim submission, payment tracking and rejection management.
While EHR systems streamline processes, reduce errors and accelerate reimbursements, medical billing professionals may face certain challenges when working with EHRs:
- Data overload: With so much information stored in EHRs, it can be time-consuming and challenging for medical billers to identify specific data relevant to the billing process.
- Complexity of EHR systems: EHR systems can have features beyond invoicing that make them extremely complicated. For billing specialists, navigating these complex interfaces and comprehending the full scope of the EHR system can be difficult.
- Interoperability issues: Many healthcare organizations use different EHR systems that don’t always communicate with each other. This can make it difficult for medical billers to access complete patient information, which can hinder the efficiency of the medical billing process.
- Compliance and regulatory changes: Even the most skilled medical billers can face difficulty in keeping up with ever-changing healthcare legislation and compliance standards. Medical billers may find it difficult to adjust to changes in coding standards, billing laws and documentation specifications, along with meeting their daily professional responsibilities.
Skills medical billers need for EHR-based billing
To succeed with the challenges of a digital health record system that uses EHR-based billing, professional medical billers require the following competencies:
EHR system proficiency:
Medical billers must become experts in major EHR platforms, such as Epic, Cerner and NextGen, to navigate the system, locate and verify information accurately and submit claims effectively and efficiently.
Knowledge of medical terminology and coding:
A strong understanding of ICD-10-CM, CPT, HCPCS Level II and modifiers helps reduce the risk of submitting claims with coding mistakes such as undercoding (assigning a lower-level code than what the documentation supports) or upcoding (coding services at a higher level than what the documentation supports).
Claims submission knowledge:
While EHRs can help automate and improve claim workflows, medical billers must understand how to manage, submit and troubleshoot them for digital billing to be effective.
Compliance knowledge:
Medical billers need extensive knowledge of the Health Insurance Portability and Accountability Act (HIPAA), payer-specific guidelines and federal billing regulations to reduce the risk of audits and compliance penalties.
Data accuracy and attention to detail:
Medical billers need the expertise necessary to identify errors in data or provider notes, verify insurance details and correct missing data that could trigger denials. While EHRs reduce the need for manual entry, the system still relies on a medical biller’s accuracy and oversight.
Commitment to continuing education:
To succeed in navigating the EHR, medical billers must remain informed about changes the fast-evolving healthcare industry. By earning professional certifications, such as the Certified Professional Biller (CPB) from the American Academy of Professional Coders (AAPC), joining professional associations and following industry updates, medical billers can keep abreast of industry changes and best practices.
Analytical thinking:
Medical billers require the ability to analyze claim data, audit documentation, diagnose claim denials and find missing documentation efficiently to reduce the amount of time services remain unpaid.
Communication skills:
Medical billers depend on strong communication skills to coordinate their needs with clinical, coding and administrative staffs to resolve billing issues and rejected claims through appropriate channels.
