Hacking Healthcare

Chapter 3. Medical Billing

Medical billing in the United States ranks, in our experience, with nuclear physics and rocket design in challenges to mastery. These fields all have incredibly steep learning curves and require years of study, patience, and experience. We are not joking about this. Medical billing is one of the most difficult tasks that can be undertaken, and performing it successfully is an extraordinary feat. The United States generates more than $3 trillion of medical spending per year, which leaves the payers (insurance, government, patients) in an all-out war to avoid paying as much as they can to the recipients such as facilities, providers, and other servicers. To put that $3 trillion number in perspective for a moment, realize that the entire federal government across all operations, including defense, spends just a little more than $3 trillion per year. Healthcare is the largest pie out there, but it is exceptionally hard to get a slice.

Between terminology, legal issues, coding, and the mechanics of claims, this chapter has an enormous amount of material to cover, so be prepared to stick around for a while. We will provide a good overview of medical billing workflows as well as a Rosetta stone for the jargon you are likely to encounter. Understand, however, that even with this chapter’s length we can only begin to scratch the surface of all that medical billing entails. Medicare alone, the federal government insurer, has more than 2 million pages of documentation ...