Gayathri Natarajan, Vice President & Head – Coding Services, Access Healthcare

At first sight, it seems odd that companies and professionals based in India (and elsewhere in Asia) have such a significant role to play in the US healthcare industry. The reason lies in some fundamental differences in how healthcare is delivered in the US. The healthcare payment system is driven by multiple factors influencing reimbursement like eligibility, insurance/payer coverages alongside documentation requirements.

The monitoring and regulatory terms associated with such a system translate to intensive and extensive documentation requirements for optimizing the expenses and tracking every dollar spent. These documentation processes put intense pressure on healthcare providers at all levels who have to deliver clinical quality care and need to spend significant money and effort on getting paid for their services rendered. 

Demand for healthcare continues to be high, but the nature of this demand is unpredictable. Healthcare systems (providers including hospitals, doctors, practices, etc.) face challenges in forecasting, resource planning and staff sourcing. Payers are slowly shifting their focus towards value-based care, meaning the payout is based on outcomes achieved from the healthcare rendered, not the cost of services/treatment. Keeping up with rising costs and changing regulations is becoming more complicated than ever, adversely affecting revenues and cash flow for the providers. The weak outlook and lack of profitability distract them from their core goal of delivering quality healthcare to the patients who rely on them.

The outsourcing advantage

Outsourcing revenue cycle management is a healthy strategy in this situation, primarily because India, the Philippines and several other Asian economies can provide in-depth domain expertise, technical support and staffing at a significant cost advantage. Healthcare providers can maintain a very agile organization and achieve timely billing, increased revenue flow and better overall financial health. This clear value proposition enabled the healthcare BPO industry to gain significant ground over the past decade in India. The revenue cycle management (RCM) professionals with US healthcare expertise, including medical coders, came in high demand. India has the highest number of medical coders working in US healthcare, second only to the USA. This is bound to expand in the coming years.

Medical Coding – Key link in the chain 

Medical coders are analogous to interpreters or language experts. In the healthcare revenue cycle world, medical coders help translate the language of medicine into meaningful code sets critical to reimbursement. They review the documentation on electronic health records, including the doctor’s assessment, interpretations of the patient’s condition and derived treatment plans considering prior health history. The medical coder reads the documentation from the provider, understands each element of the encounter to the most minute details, refers to the codebooks, chooses the right standard codes from the databases to describe every relevant point, and reports the same to the payer. The principles ascribed translate to standardized code libraries or standards such as the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), etc. These datasets are comprehensive lists of all symptoms, disorders, conditions, treatments and interventions currently prevalent in medical science. The payer, usually the insurance company, processes these code sets (a concise and standardized version of the original clinical documentation) to make decisions on the payment of claims and, thereby, a healthcare provider’s revenue.

The ideal Medical Coder

As the medical codes serve as the standard language for interpreting medical conditions and care provided between the payer and provider, accuracy and thoroughness are of utmost importance in medical coding. Coders must have speed and attention to detail, besides sufficient knowledge of human anatomy, medical terminologies, and healthcare practices, to effectively interpret the clinical documentation. They must have excellent analytical abilities to assign codes consistently and precisely from the correct databases.

Just like there are specialists and super-specialists among doctors, the community of medical coders also have a system of specializations and speciality-specific certifications to ensure accurate Medical coding is delivered. The American Association of Professional Coders (AAPC), American Health Information Management Association and other bodies certify coders who have gained a certain level of expertise in the profession.

Opportunities for Coders

The heavy demand for coders has also opened up opportunities for independent operators who can get work on a freelance basis. However, the high level of data security, continuous skill enhancements and intensive quality control protocols make well-structured organizations more favourable in the market. 

New technology and remote working models allow coders to practice their craft from anywhere in the world. Coders with 3-4 years of solid experience can grow into auditors, team leaders and managers who supervise and maintain the service delivery and quality of a team of coders. Demonstrating one’s abilities on all fronts is critical for growth, with career paths extending all the way to top organizational leadership lying open for the right talent.