Health Maintenance Organization Act

Chapter One Summary

Since the enactment of the Health Maintenance Organization Act of 1973 and the establishment of the Managed Care system, the billing system, and consequently, the employment demand in the healthcare system changed. Before the act, physicians could open a private health care facility and hire staff depending on customer traffic. However, in Managed Care, the payment process is long and extensive, necessitating the hiring of 60% of allied healthcare employees against 40% physicians and nurses in a health facility. Allied personnel is an employee in the healthcare profession who are distinctly not a medical or nursing professional. The physician practices, multispecialty of a clinic, hospital, and a centralized billing office influences the hiring of allied health personnel. For instance, a solo facility may have one allied personnel, while an extensive group practice may employ several allied personnel.

The knowledge about medical billing and coding is critical for allied healthcare personnel, and it impacts their job titles and responsibilities. Once a student has completed a course, they may become an ally through entry-level jobs in a healthcare facility. Some title includes the medical biller, admitting clerk, medical office assistant, refund specialist, payment poster, insurance verification representative, and medical collector.

Some facilities hire cross-trained allies to undertake more than one role, depending on the size of a facility. For instance, a medical assistant may be the secretary, receptionist, and administrative assistant. Their role is mainly administrative duties in the office of the physician. The admitting clerk is the first staff to engage patients face-to-face by greeting and registering them. A medical biller analyzes data concerning patients charges, submits claims to the payer, and obtains balances from the payer or the patient. They manage the sophisticated insurance process that has many laws, regulations, and guidelines concerning various types of facilities and coverage. A payment poster is a data entry and math specialist, who is conversant with insurance contracts. They read and interpret the insurer’s benefits document to post appropriate payments on patients. Before a patient is covered, an insurance verification representative determines the financial responsibilities of various stakeholders, and pre authenticates or nullifies the coverage. A medical collector is a good communicator, who follows up the payment process, and contacts both patients and insurance carriers concerning the collection of money owed by the facility. A refund specialist analyzes the legitimacy of the claim, the possible value of refund, and the time to pay a refund.

At every level of expertise in medical billing and coding, certification is valuable. In most states, certification does not add competitiveness in hiring, but it increases the potential to further one’s medical billing and coding career and redefines a job title. For instance, medical office assistance becomes a Certified Medical Administrative Assistant (CMAA), and a medical billing officer becomes a Certified Medical Reimbursement Specialist (CMRS). Similarly, certification changes the title for all allied healthcare job titles. Some certification agencies are the American Academy of Professional Coders and the National Healthcare Association, among others. The best way to select a certification agency is to find them from accreditation organizations such as the Commission of Accreditation of Allied Health Education Programs.

Besides certification, professional membership is an excellent addition to one’s resume. It increases access to professional information and opportunities such as conferences and vacancies. Allied professionals may register in states, regions, or national membership organizations to keep up to date with professional developments in their field, or take part in journal publishing.