Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Insurance Specialist Career Chapter 1

Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Health

Insurance Specialist Career

Chapter 1


Career Opportunities

• Health insurance and reimbursement specialists review claims received by insurance carriers to determine that “medical necessity” is proven for procedures and services submitted.


Location of Code for CMS-1500

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• A claims examiner employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable and meet the criteria for medical necessity.



• 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



• A medical assistant is employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.



• Coding is the process of assigning ICD-9-CM and CPT/HCPCS codes to diagnoses, procedures, and services. Coding systems include– International Classification of Diseases, 9th Revision,

Clinical Modification (ICD-9-CM)The following will be implemented on October 1, 2013– International Classification of Diseases, 10th Revision,

Clinical Modification (ICD-10-CM)– International Classification of Diseases, 10th Revision,

Procedural Coding System (ICD-10-PCS)



• Healthcare Common Procedure Coding System– Current Procedural Terminology (CPT)– HCPCS level II codes (national codes)


Opportunities Available

• Claims benefit advisors

• Coding or insurance specialists

• Educators in schools

• Writers and editors

• Self-employed consultants

• Private billing practices


Opportunities for Insuranceand Reimbursement Specialists

• Advisors on claims submitted– Health insurance claims

– Malpractice

– Liability insurance carriers


Opportunities for Insuranceand Reimbursement Specialists

(cont.)• State, local, and federal government

agencies

• Legal offices

• Private insurance billing offices

• Medical societies


Opportunities for Insurance and Reimbursement Specialists

(cont.)• Medical practice consultants

• Auditors

• Compliance monitors


Opportunities for Insurance and Reimbursement Specialists

(cont.)• Instructors for community education

programs specializing in training medical billers and coders

• Textbook writers

• Newsletter writers

• Industry publications


Overview of Role of Insurance Specialist

• Responsible for filing health insurance claims

• Handles timely reimbursement for appropriate documentation submitted


Contracting Decisions

• Healthcare practices need to make important decisions on signing contracts with individual insurance carriers

– Authorization requirements

– Billing deadlines

– Claims requirements

– Participating provider networks


How Does an Insurance Specialist Stay Up-to-Date?

• Receive carrier newsletters

• Understand your contracts

– Know when they are renewed.

– Make notes on parts that are not

running as expected.

– Know your provider’s relations agent.


How Does an Insurance Specialist Stay Up-to-Date?

(cont.)• Remain current

– Regarding news releases from CMS– Regarding changes in industry– Regarding new technology


Education and Training

• HCPCS coding systems

• ICD-9-CM and ICD-10-CM and ICD-10-PCS coding systems

• Anatomy and physiology

• Communication skills

• Human relations

• Computer applications


Skills Needed

• Insurance specialist positions require– Background in word processing

– Knowledge of

• Computer applications


• Medical terminology

• Insurance claims processing


Skills Needed (cont.)

– Excellent keyboarding skills

– Basic math skills

– In this detail-oriented industry • Typographical errors can completely change the

information provided.


Characteristics of Insurance Specialists

• Ability to work independently

• Strong sense of ethics

• Ability to pay attention to detail

• Ability to think critically


Definition of Ethics

• The American Heritage Concise Dictionary– “Principles of right or good conduct and the rules that

govern the conduct of members of a profession”


Why Training Is Necessary in Coding

• Health insurance specialists– Must understand guidelines and applications of the

coding systems to ensure proper selection of codes reported on insurance claims for reimbursement purposes


Communication Skills Needed

• Health insurance specialists– Need to explain complex concepts and regulations to

effectively communicate with their providers regarding documentation requirements to reduce errors


Communication Skills Needed

• Written communication skills are needed when preparing effective appeals for unpaid claims.– Critical thinking

• Differentiating technical descriptions or similar procedures requires critical thinking.


Training Requirements


• Coding

• Communication

• Critical thinking

• Data entry

• Internet access


Student Internship

• 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.


Medical Assistant and Internship Student Prepare for a Patient

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Job Description

• Analyze documentation and code all diagnoses, procedures, and services.

• Know all rules and regulations for major insurance programs.

• Accurately post charges, payments, and adjustments to accounts.


Job Description (cont.)

• Prepare and review claims generated to ensure accuracy and expedite reimbursement.

• Review insurance payments and remittance advice.

• Correct data errors and resubmit all unprocessed or returned claims.



• Research and appeal all underpaid or denied claims.

• Trace all claims not paid within 30 to 45 days and rebill if necessary.

• Notify staff and providers of any changes in coding or documentation guidelines affecting denials.



• Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements.

• Maintain internal audit system.



• Explain benefits, policy requirements, filing requirements, and payments to patients.

• Maintain confidentiality of patient information.


Scope of Practice

• Work with patients to make clear what their health insurance covers and their financial responsibility.


Employer Liability

• Self-employed – Independent contractors– Professional liability insurance

• Respondeat superior – “Let the master answer”


Qualifications

• Graduate of health insurance specialist certificate or degree program

• Understanding of insurance billing/collection processes

• Outstanding organizational skills and aptitude to manage multiple tasks in a timely manner


Qualifications (cont.)

• Proficient use of registration and billing systems as well as personal computer software (i.e., MS Word, Excel, etc.)

• Consider certification through AAPC, AHIMA, and AMBA


Responsibilities

• Knowledge of medical management computer software to process health insurance claims

• Knowledge of insurance coverage, repayment issues, and healthcare laws and regulations


Responsibilities (cont.)

• Communication with insurance companies and patients regarding coverage and reimbursement issues


Supervision Requirements

• Continual observation of health insurance specialist is mandatory.

• Supervisors, however, may not always be in attendance when responsibilities of the specialist are performed.


Employer Insurance

• Bonding insurance– Contract ensures repayment for financial losses

resulting from an employee’s act.

• Business liability insurance– Defends business property and covers the cost of

lawsuits resulting from bodily and personal injury.


Professional Insurance

• Property insurance– Protects business contents against fire, theft, and other

risks.

• Workers’ compensation insurance – State law covers employees in the event they are

injured on the job.

– Helps with medical and financial needs of those who have work-related injuries.


Professionalism

• Conduct or qualities that characterize a professional person– Attitude and self-esteem

– Communication

– Conflict management

– Customer service

– Diversity awareness


Professionalism (cont.)

– Leadership

– Managing change

– Productivity

– Professional ethics

– Team building


Telephone Skills

• All healthcare team members must effectively handle or transfer telephone calls. – Requires sensitivity to patient concerns about

healthcare problems; the healthcare professional must communicate a caring environment that leads to patient satisfaction.


Telephone Skills (cont.)

• 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 healthcare setting.



– Inform callers who want to speak with the physician (or another healthcare provider) that the physician (or provider) is with a patient.

– Assign 15-minute time periods every two to three hours when creating the schedule, so physicians (and other healthcare 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.


Professional Associations

• American Academy of Professional Coders (AAPC)

• American Association of Medical Assistants (AAMA)

• American Health Information Management Association (AHIMA)


Professional Associations (cont.)

• American Medical Billing Association (AMBA)

• Medical Association of Billers (MAB)

Documents

Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Insurance Specialist Career Chapter 1