Providers and their staff are confused too—trust me, you are not alone

When a young person heads off to medical school, they dream of caring for patients and inventing new ways to provide care. Reality hits when they move into residency, where they quickly find out that there is a business side to medicine. They have to be taught to document what they do in a patient’s chart, learn how to assign codes that tell insurance companies what they did (CPT – Current Procedural Terminology) and what was wrong with the patient (DX – Diagnosis), in order to receive payment for their services.

Ask any medical professional if they went to school to help people or to become business majors? They will most likely tell you they did it to help people, but they still must make a living, and it’s complicated to do so in medicine. Often, they think that they will be the ones to outthink insurance companies, and that rarely happens.

What is it about the healthcare industry that is so confusing? There are many layers to this onion, so I will peel them back one-by-one.

Insurance Companies

Let’s start with insurance companies. Most insurance companies have a complicated process to establish business with them, and their rules and rates vary greatly. Think about how complicated dealing with tax law is, which is why we hire people to do it for us, and then apply that to insurance companies. Accountants and bookkeepers have a lot of training and well-written software to assist them, but in healthcare these are lacking.

Providers of healthcare engage in the contract process with insurance companies, and sadly, they only focus on the compensation they will receive for their services. The contracts don’t contain the rules for billing the insurance companies for the services provided—those seem to be buried somewhere in the deep dark web!

When a provider of healthcare recommends services or provides you with services, unless they have called your insurance company with the specific CPT codes they will use or recommend using to verify your benefits, they know about as much as you do. For example, let’s say you go to the doctor, and after the examination, they determine you would benefit from a steroid injection for your allergies. You say ok, accept the injection, and then thirty days later receive a bill for the cost. Why? Maybe your deductible wasn’t met, you had a co-insurance, you could have been billed incorrectly…who knows, but the bottom line is, they didn’t tell you your responsibility prior to service, because neither of you knew.

The moral of the story is not to assume that just because they are contracted with your insurance company and in the medical field they’ll know the ins and outs of your insurance policy. It truly is in your best interest that you now exactly what’s covered, what’s not, and what you owe for things.

Staff Education

Over the last twenty years, despite degree programs proliferating in colleges, along with classes and certification courses to help educate healthcare professionals, most employees in healthcare are “taught” by the person sitting next to them.

I’ve had the opportunity to work with college-educated individuals in healthcare, and the ones who are sharpest worked in the industry in addition to obtaining a degree. There are organizations like the MGMA (Medical Group Management Association) and HFMA (Healthcare Financial Management Association) that offer courses and certifications, but those efforts are limited unless you’ve worked in the trenches. Do they help? A little, but until you’ve spent years combing through insurance company denials you won’t fully understand that finding the rules that get the provider of healthcare paid for their services is all that matters.

The most common training technique is the shoulder-to-shoulder process, and since most are trained this way, you run into the largest gaps in knowledge or bad information passed on. My favorite line is, “But this is what I was told to do, ugh!” With the age of the internet and the ability to research online, there is no reason we shouldn’t have a better-educated workforce in healthcare.

Staff Selection

When I would hire people for my business, I would give them a billing test, and in addition, I would ask them to write out a scenario of a difficult denial they had and what they did to resolve it. This helped me to determine their strengths and identify gaps we would need to fill.

The billing test is self-explanatory, but the written test always produced the most interesting results. I liked looking at their thought process, their ability to communicate effectively, and their overall problem-solving skills, because we were solving lots of problems daily.

In large health organizations, you tend to find more well-defined training programs and policies and procedures that staff must follow, but in the smaller practices and ancillary services, not so much.

The pay offered in the smaller practices isn’t awesome; they rarely get out for continuing education, and they lack strong formalized policies for everyone to follow. Additionally, you will find that the front desk person is often the practice manager, because it’s cheaper.

Our industry is difficult, and often the people you come across were thrown into these jobs, with very little initial or ongoing training, expected to simply figure it out.


In an industry whereby one CPT code can have different rules for reimbursement by each insurance company a provider is contracted with, they continue to rely on the human brain to remember all those nuances. If you have a limited amount of CPT codes, maybe this could work, but most don’t.

Many healthcare entities don’t leverage technology to help themselves or you. They barely use it to appropriately document your visit—more importantly, in their minds, it is to process your insurance claims for reimbursement.

Unless you work at a major or university hospital that has a fulltime IT department, the mid-to-small practices have their software built and maintained by staff, all while doing their other jobs.

There is hope on the horizon, though. With the emergence of artificial intelligence (AI) and robotic process automation (RPA) to help scrub denials and apply that technology to the claims, or even to check your insurance and benefits prior to service, we will head in the right direction.

The big question is: Will healthcare providers pay for the help they desperately need?

When I write these articles, I always read them to my husband to see if my message is clear, and after reading this to him, this was his answer: “Wow, healthcare providers and their staff don’t know all that much either, and we assume when we go somewhere for care that they do.” He nailed it!

Patients assume that healthcare entities know everything about their insurance policy and financial obligations, yet most of the time this just isn’t the case. It is why you continue to receive bills you didn’t think you would get and why it’s imperative for you to learn your policy and understand your obligations.

The next time you step into a healthcare provider’s place of business, remember, they may or may not know your policy’s ins and outs, so make sure that you do!



  1. If you go to a provider of healthcare for a specific reason and additional services are recommended, ask the cost and what your responsibility will be before saying yes.
  2. If a provider of healthcare says that they don’t know your cost, ask for the CPT codes and call your insurance company and get the information for yourself, then schedule the service.
    1. Get the name of the agent who gave you the information because if they give you incorrect information, and they do, you can file an appeal with that information.
  3. Get as much as you can in writing, or at the very least get names, dates and confirmation numbers when you get information from people. A lot of incorrect information is given and helps you to get items adjusted off, appealed or corrected.
  4. Know your policy and what things will cost you—broken record, I know, but it’s true. The only way to become a healthcare consumer is to understand what your policy covers and why.

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