Chapter 1

1. Chapter 1 Health Insurance Specialist Career

2. OVERVIEW This chapter presents an overview of the • health insurance specialist career • background necessary for education and training, • responsibilities on the job, and • professional credentialing opportunities

3. Health Insurance Specialist IMPORTANT! • Define key terms. • Discuss introductory health insurance concepts. • Identify career opportunities. • List the education and training requirements. • Describe the job responsibilities. • Explain the role of workplace professionalism in career success.

4. 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.

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

6. Career Opportunities • 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

7. Career Opportunities • Medical assistant isemployed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.

8. Career Opportunities • 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)

9. Career Opportunities • Health Care Common Procedure Coding System • Current Procedural Terminology (CPT) • HCPCS Level II codes (national codes)

10. Opportunities Available • Claims benefit advisors • Coding or insurance specialists • Educators in schools • Writers and editors • Self-employed consultants • Private billing practices

11. Opportunities for Insuranceand Reimbursement Specialists • Advisors on claims submitted • Health insurance claims • Malpractice • Liability insurance carriers

12. Opportunities for Insuranceand Reimbursement Specialists • State, local, and Federal government agencies • Legal offices • Private insurance billing offices • Medical societies

13. Opportunities for Insurance and Reimbursement Specialists • Medical practice consultants • Auditors • Compliance monitors

14. Opportunities for Insurance and Reimbursement Specialists • Instructors for community education programs specializing in training medical billers and coders • Textbook writers • Newsletter writers • Industry publications

15. Overview of Role of Insurance Specialist • Responsible for filing health insurance claims • Handle timely reimbursement for appropriate documentation submitted

16. Contracting Decisions • Health care practices need to make important decisions on signing contracts with individual insurance carriers: A. Authorization requirements B. Billing deadlines C. Claims requirements D. Participating provider networks

17. How Does an Insurance Specialist Stay Up-to-Date? A. Receive carrier newsletters 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

18. How Does an Insurance Specialist Stay Up-to-Date? C. Remain Current 1. Regarding news releases from CMS 2. Changes in industry 3. New technology

19. Education and Training • Understanding HCPCS coding systems • ICD-9-CM coding systems • Anatomy and physiology • Communication skills • Human relations • Computer applications

20. Skills Needed • Insurance specialist positions require • Background in word processing • Knowledge of computer applications • Anatomy and physiology • Medical terminology • Insurance claims processing

21. Skills Needed • Excellent keyboarding skills • Basic math skills • In this detail-oriented industry • Typographical errors can completely change the information provided

22. Characteristics of Insurance Specialists • Ability to work independently • Strong sense of ethics • Ability to pay attention to detail • Ability to think critically

23. 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”

24. 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

25. 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

26. 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.

27. Training Requirements • Anatomy and physiology • Coding • Communication • Critical thinking • Data entry

28. 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. • RTC’s coding program has a mandatory 180 hour externship. Reimbursement specialists have an OPTIONAL, but encouraged, externship.

29. 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

30. Job Description • Prepare and review claims generated to ensure accuracy and expedite reimbursement • Review insurance payments and remittanceadvice • Correct data errors and resubmit all unprocessed or returned claims

31. Job Description • Research and appeal all underpaid or denied claims • Trace all claims not paid within 30–45 days and rebill if necessary • Notify staff and providers of any changes in coding or documentation guidelines effecting denials

32. Job Description • Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements • Maintain internal audit system

33. Job Description • Explain benefits, policy requirements, filing requirements, and payments to patients • Maintain confidentiality of patient information

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

35. Employer Liability • Self-employed – Independent contractors • Professional liability insurance • Respondeat Superior – “Let the master answer”

36. 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

37. Qualifications • 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

38. Responsibilities • Knowledge of medical management computer software to process health insurance claims • Knowledge of insurance coverage, repayment issues, and health care laws and regulations

39. Responsibilities • Communicate with insurance companies and patients regarding coverage and reimbursement issues

40. 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.

41. Employer Insurance • Bonding Insurance • Contract ensures repayment for financial losses resulting from an employee’s act. • Business Liability Insurance • Defends business property and covers cost of lawsuits resulting from bodily and personal injury

42. Professional Insurance • Property Insurance • Protection of 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

43. Professionalism KEY to SUCESS • Conduct or qualities that characterize a professional person • Attitude and self-esteem • Communication • Conflict management • Customer service • Diversity awareness

44. Professionalism • Leadership • Managing change • Productivity • Professional ethics • Team building

45. Telephone Skills • All health care team members must effectively handle or transfer telephone calls. • Requires sensitivity to patient concerns about health care problems, and the health care professional must communicate a caring environment that leads to patient satisfaction

46. Telephone Skills • 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

47. Telephone Skills • 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.

48. Telephone Skills • Physically separate front desk check-in/check-out and receptionist/patient appointment scheduling offices • Require office employees to learn professional telephone skills

49. Professional Associations • American Academy of Professional Coders (AAPC) • American Association of Medical Assistants (AAMA) • American Health Information Management Association (AHIMA) • American Medical Billing Association (AMBA)

50. Professional Associations • Medical Association of Billers (MAB) • National Electronic Billers Alliance (NEBA)