PMI: Doctors Frustrated with Ever-Changing Reimbursement Regulations Turn to Certified Medical Coders for Help

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The regulations governing medical reimbursement have changed tremendously in recent years and will continue to evolve as payment models shift from fee-for-service to pay-for-performance. More private practice physicians are looking for certified medical coders to help them meet regulatory requirements and collect proper reimbursement, so they can focus on patient care.

Physicians devote decades to medical education with the goal of treating the sick and saving lives. However, they are spending as much as 43% of their time jumping through administrative hoops required for reimbursement.(1) Very little of a physician’s professional training involves the business aspect of practicing medicine, and more independent providers are looking to certified medical coders for help.

The revenue cycle in a medical office is reliant on the quality and accuracy of the documentation provided about a patient encounter. Insurance carrier rules require physicians to provide specific diagnosis and procedure information in the documentation. Coders then apply the proper codes from these notes to obtain complete reimbursement for services rendered.(2) A key part of the solution, says industry leader Practice Management Institute (PMI), is to employ Certified Medical Coders (CMC), reimbursement professionals trained by PMI to work within proper guidelines and submit correct claims.

David Womack, CEO of PMI, says, “The healthcare reimbursement system is very detailed making it very challenging for physicians to keep up, and reliance on technology is a bad idea. Certified Medical Coders have completed formal training on coding rules, guidelines and working with third-party carriers to get claims paid. You need a highly skilled person able to communicate with the physician and the carriers on claims and fight for reimbursement that is rightfully due to the practice.”

The rules for submitting claims with government programs like Medicare are very detailed with some guidelines updated annually. Just one improperly coded claim could cost thousands of dollars.(3)

Billing and insurance-related administrative costs in the U.S. have skyrocketed. BMC Health Services Research found that time spent coding, filing claims and obtaining prior authorizations, cost the U.S. healthcare system as much as $471 billion in 2012.(4)

An average of $83,000 is lost every year as doctor offices wade through third-party carrier contracting agreements. They have to follow strict guidelines for claim submissions, verifying in-network benefits, prior authorizations, coverage for drugs and services, and other details in order to receive payment for services rendered.(5) Still, insurance companies collect more than 40% of all primary care revenue in profit and claims processing annually. (6)

“The value of hiring Certified Medical Coders is well-worth it,” says Womack. “These employees perform at a higher standard; they’re able to complete their jobs with greater specificity and accuracy. They understand how to protect the practice’s financial health by helping to limit audit liability and decrease claim denials, which can save providers thousands of dollars each year.”

He said PMI’s Certified Medical Coder training program is recognized by the Centers for Medicare and Medicaid Services (CMS) as an example coding certification source for its Intermediary Provider Customer Service Program. (7)

“This recognition by CMS and hundreds of other healthcare organizations reinforces PMI’s position as a leading provider of certification for medical coding professionals.”

Womack says, “Proper training and certification is so important to make sure the people responsible for medical coding are up-to-date on the latest regulations, and certified medical coders help bring that assurance to healthcare practices nationwide.”

About Practice Management Institute (PMI):
For over 30 years, Practice Management Institute (PMI) has helped physicians, hospital systems, medical societies and educational institutions to provide comprehensive, up-to-date training for medical office staff nationwide. PMI training and certification programs build competency, compliancy and effectiveness. A well-trained staff helps ease the administrative burden of running a successful medical practice, and allows physicians focus on patient care and improve the overall patient experience.
Since PMI’s formation in 1983, more than 20,000 individuals have earned PMI certification in one or more areas of expertise. PMI is recognized by the Department of Labor for its training programs for medical office coders, third-party billing, office management, and compliance staff. For more information, visit
About David Womack:
David Womack, president and CEO of PMI, has been instrumental in PMI’s continued success since 1991. He has helped PMI transition into a cutting-edge leader in medical office staff education and training while developing key relationships with healthcare organizations, hospitals, colleges, and medical societies across the country. His commitment to excellence has helped PMI become an industry leader recognized by both governmental organizations and healthcare systems across the country.

1.    Regulations strangling medical profession. The San Diego Union-Tribune.
2.    Declining reimbursement and the physicians. SPi Healthcare.
3.    The impact of medical coding on a hospital’s bottom line. Real Time Medicare Data.

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Karla Jo Helms
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