Chapter 1


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  • Coding systems include: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Health Care Common Procedure Coding System Current Procedural Terminology (CPT) HCPCS Level II codes (national codes)
  • The claims review process requires Verification of the claim for completeness and accuracy Comparison with third-party payer guidelines (e.g., expected treatment practices) to authorize appropriate payment refer the claim to an investigator for a more thorough review Medical assistant is employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.
  • Medical practice consultants Auditors Compliance monitors Instructors for community education programs specializing in training medical billers and coders Textbook writers Newsletter writers Industry publications
  • B. Understand your contracts 1. When are they renewed? 2. Make notes on parts that are not running as expected 3. Know your provider’s relations agent C. Remain Current 1. Regarding news releases from CMS 2. Changes in industry 3. New technology
  • Skills needed: Background in word processing Knowledge of computer applications Anatomy and physiology Medical terminology Insurance claims processing Excellent keyboarding skills Basic math skills In this detail-oriented industry Typographical errors can completely change the information provided
  • Benefits students and facilities that accept students for placement Students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment. Facilities benefit from the opportunity to participate in and improve the formal education process.
  • Employer Liability Self-employed – Independent contractors Professional liability insurance Respondeat Superior – “Let the master answer”
  • Avoid problems: Establish a telephone-availability policy that works for patients and office staff Set up an appropriate number of dedicated telephone lines (e.g., appointment scheduling, insurance, and billing) based on the function and size of the health care setting Inform callers who want to speak with the physician (or another health care provider) that the physician (or provider) is with a patient. Assign 15-minute time periods every 2–3 hours when creating the schedule, so physicians (and other health care providers) can return telephone calls. Physically separate front desk check-in/check-out and receptionist/patient appointment scheduling offices Require office employees to learn professional telephone skills
  • Chapter 1

    1. 1. Health Insurance Specialist Career Chapter 1
    2. 2. Career Opportunities <ul><li>Coding is the process of assigning ICD-9-CM and CPT/HCPCS codes to diagnoses, procedures, and services. </li></ul>
    3. 3. Career Opportunities <ul><li>Health insurance and reimbursement specialists review claims received by insurance carriers to determine that “medical necessity” is proven for procedures and services submitted. </li></ul><ul><li>A claims examiner employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable and for medical necessity </li></ul>
    4. 4. Opportunities for Insurance and Reimbursement Specialists <ul><li>State, local, and Federal government agencies </li></ul><ul><li>Legal offices </li></ul><ul><li>Private insurance billing offices </li></ul><ul><li>Medical societies </li></ul>
    5. 5. Overview of Role of Insurance Specialist <ul><li>Responsible for filing health insurance claims </li></ul><ul><li>Handle timely reimbursement for appropriate documentation submitted </li></ul>
    6. 6. How Does an Insurance Specialist Stay Up-to-Date? <ul><li>A. Receive carrier newsletters </li></ul><ul><li>B. Understand your contracts </li></ul><ul><li>C. Remain Current </li></ul>
    7. 7. Education and Training <ul><li>Understanding HCPCS coding systems </li></ul><ul><li>ICD-9-CM coding systems </li></ul><ul><li>Anatomy and physiology </li></ul><ul><li>Communication skills </li></ul><ul><li>Human relations </li></ul><ul><li>Computer applications </li></ul>
    8. 8. Training Requirements <ul><li>Anatomy and physiology </li></ul><ul><li>Coding </li></ul><ul><li>Communication </li></ul><ul><li>Critical thinking </li></ul><ul><li>Data entry </li></ul><ul><li>Student internship </li></ul>
    9. 9. Why Training Is Necessary in Coding <ul><li>Health insurance specialists: </li></ul><ul><ul><li>Must understand guidelines and applications of the coding systems to ensure proper selection of codes reported on insurance claims for reimbursement purposes </li></ul></ul><ul><ul><li>Need to explain complex concepts and regulations to effectively communicate with their providers regarding documentation requirements to reduce errors </li></ul></ul>
    10. 10. Characteristics of Insurance Specialists <ul><li>Ability to work independently </li></ul><ul><li>Strong sense of ethics </li></ul><ul><li>Ability to pay attention to detail </li></ul><ul><li>Ability to think critically </li></ul>
    11. 11. Communication Skills Needed <ul><li>Written communication skills are needed when preparing effective appeals for unpaid claims. </li></ul><ul><ul><li>Critical thinking: </li></ul></ul><ul><ul><ul><li>Differentiating technical descriptions or similar procedures requires critical thinking. </li></ul></ul></ul>
    12. 12. Job Description <ul><li>Analyze documentation and code all diagnoses, procedures, and services </li></ul><ul><li>Know all rules and regulations for major insurance programs </li></ul><ul><li>Accurately post charges, payments, and adjustments to accounts </li></ul>
    13. 13. Job Description <ul><li>Prepare and review claims generated to ensure accuracy and expedite reimbursement </li></ul><ul><li>Review insurance payments and remittance advice </li></ul><ul><li>Correct data errors and resubmit all unprocessed or returned claims </li></ul>
    14. 14. Job Description <ul><li>Research and appeal all underpaid or denied claims </li></ul><ul><li>Trace all claims not paid within 30–45 days and rebill if necessary </li></ul><ul><li>Notify staff and providers of any changes in coding or documentation guidelines effecting denials </li></ul>
    15. 15. Job Description <ul><li>Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements </li></ul><ul><li>Maintain internal audit system </li></ul><ul><li>Explain benefits, policy requirements, filing requirements, and payments to patients </li></ul><ul><li>Maintain confidentiality of patient information </li></ul>
    16. 16. Scope of Practice <ul><li>Work with patients to make clear what their health insurance covers and their financial responsibility </li></ul>
    17. 17. Qualifications <ul><li>Graduate of health insurance specialist certificate or degree program </li></ul><ul><li>Understanding of insurance billing/collection processes </li></ul><ul><li>Outstanding organizational skills and aptitude to manage multiple tasks in a timely manner </li></ul><ul><li>Proficient use of registration and billing systems as well as personal computer software (i.e., MS Word, Excel, etc.) </li></ul><ul><li>Consider certification through AAPC, AHIMA, and AMBA </li></ul>
    18. 18. Responsibilities <ul><li>Knowledge of medical management computer software to process health insurance claims </li></ul><ul><li>Knowledge of insurance coverage, repayment issues, and health care laws and regulations </li></ul><ul><li>Communicate with insurance companies and patients regarding coverage and reimbursement issues </li></ul>
    19. 19. Professionalism <ul><li>Conduct or qualities that characterize a professional person </li></ul><ul><ul><li>Attitude and self-esteem </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Conflict management </li></ul></ul><ul><ul><li>Customer service </li></ul></ul><ul><ul><li>Diversity awareness </li></ul></ul><ul><ul><li>Leadership </li></ul></ul><ul><ul><li>Managing change </li></ul></ul><ul><ul><li>Productivity </li></ul></ul><ul><ul><li>Professional ethics </li></ul></ul><ul><ul><li>Team building </li></ul></ul>
    20. 20. Telephone Skills <ul><li>All health care team members must effectively handle or transfer telephone calls. </li></ul><ul><ul><li>Requires sensitivity to patient concerns about health care problems, and the health care professional must communicate a caring environment that leads to patient satisfaction </li></ul></ul>
    21. 21. Professional Associations <ul><li>American Academy of Professional Coders (AAPC) </li></ul><ul><li>American Association of Medical Assistants (AAMA) </li></ul><ul><li>American Health Information Management Association (AHIMA) </li></ul><ul><li>American Medical Billing Association (AMBA) </li></ul><ul><li>Medical Association of Billers (MAB) </li></ul><ul><li>National Electronic Billers Alliance (NEBA) </li></ul>