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Health
Insurance Specialist Career
Chapter 1
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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.
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Location of Code for CMS-1500
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Career Opportunities
• 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.
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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
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Career Opportunities
• A medical assistant is employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.
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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)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)
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Career Opportunities
• Healthcare Common Procedure Coding System– Current Procedural Terminology (CPT)– HCPCS level II codes (national codes)
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Opportunities Available
• Claims benefit advisors
• Coding or insurance specialists
• Educators in schools
• Writers and editors
• Self-employed consultants
• Private billing practices
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Opportunities for Insuranceand Reimbursement Specialists
• Advisors on claims submitted– Health insurance claims
– Malpractice
– Liability insurance carriers
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Opportunities for Insuranceand Reimbursement Specialists
(cont.)• State, local, and federal government
agencies
• Legal offices
• Private insurance billing offices
• Medical societies
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Opportunities for Insurance and Reimbursement Specialists
(cont.)• Medical practice consultants
• Auditors
• Compliance monitors
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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
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Overview of Role of Insurance Specialist
• Responsible for filing health insurance claims
• Handles timely reimbursement for appropriate documentation submitted
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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
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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.
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How Does an Insurance Specialist Stay Up-to-Date?
(cont.)• Remain current
– Regarding news releases from CMS– Regarding changes in industry– Regarding new technology
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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
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Skills Needed
• Insurance specialist positions require– Background in word processing
– Knowledge of
• Computer applications
• Anatomy and physiology
• Medical terminology
• Insurance claims processing
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Skills Needed (cont.)
– Excellent keyboarding skills
– Basic math skills
– In this detail-oriented industry • Typographical errors can completely change the
information provided.
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Characteristics of Insurance Specialists
• Ability to work independently
• Strong sense of ethics
• Ability to pay attention to detail
• Ability to think critically
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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”
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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
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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
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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.
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Training Requirements
• Anatomy and physiology
• Coding
• Communication
• Critical thinking
• Data entry
• Internet access
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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.
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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.
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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.
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Job Description (cont.)
• 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.
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Job Description (cont.)
• Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements.
• Maintain internal audit system.
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Job Description (cont.)
• Explain benefits, policy requirements, filing requirements, and payments to patients.
• Maintain confidentiality of patient information.
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Scope of Practice
• Work with patients to make clear what their health insurance covers and their financial responsibility.
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Employer Liability
• Self-employed – Independent contractors– Professional liability insurance
• Respondeat superior – “Let the master answer”
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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
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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
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Responsibilities
• Knowledge of medical management computer software to process health insurance claims
• Knowledge of insurance coverage, repayment issues, and healthcare laws and regulations
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Responsibilities (cont.)
• Communication with insurance companies and patients regarding coverage and reimbursement issues
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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.
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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.
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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.
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Professionalism
• Conduct or qualities that characterize a professional person– Attitude and self-esteem
– Communication
– Conflict management
– Customer service
– Diversity awareness
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Professionalism (cont.)
– Leadership
– Managing change
– Productivity
– Professional ethics
– Team building
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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.
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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.
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Telephone Skills (cont.)
– 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.
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Telephone Skills (cont.)
– Physically separate front desk check-in/check-out and receptionist/patient appointment scheduling offices.
– Require office employees to learn professional telephone skills.
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Professional Associations
• American Academy of Professional Coders (AAPC)
• American Association of Medical Assistants (AAMA)
• American Health Information Management Association (AHIMA)