copyright © 2008 delmar learning. all rights reserved. chapter 1 health insurance specialist career

Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 1

Health Insurance

Specialist Career

Copyright © 2008 Delmar Learning. All rights reserved.

2

Career Opportunities

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

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3

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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4

Opportunities for Insurance and Reimbursement Specialists

• Advisors on claims submitted– Health insurance claims– Malpractice – Liability insurance carriers

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5

Opportunities for Insurance and Reimbursement Specialists

• State, local, and Federal government agencies

• Legal offices

• Private insurance billing offices

• Medical societies

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6

Opportunities for Insurance and Reimbursement Specialists

• Medical practice consultants

• Auditors

• Compliance monitors

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7

Opportunities for Insurance and Reimbursement Specialists

• Instructors for community education programs specializing in training medical billers and coders

• Textbook writers

• Newsletter writers

• Industry publications

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8

Overview of Role of Insurance Specialist

• Responsible for filing health insurance claims

• Handle timely reimbursement for appropriate documentation submitted

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9

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

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10

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 relations agent

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11

Remain Current

• Regarding news releases from CMS

• Changes in industry

• New technology

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12

Professional Credentials

• Health insurance specialists who become members of specialized associations receive helpful information:– Professional journals– Newsletters

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13

AAPC Credentials

• American Academy of Professional Coders (AAPC)

– CPC-A: Certified Professional Coder Apprentice

– CPC-HA: Certified Professional Coder- Hospital Apprentice

– CPC: Certified Professional Coder

– CPC-H: Certified Professional Coder- Hospital

– CPC-P: Certified Professional Coder-Payer

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14

AHIMA Credentials

• American Health Information Management Association (AHIMA)

– CCA: Certified Coding Associate – CCS: Certified Coding Specialist– CCS-P: Certified Coding Specialist-

Physician-Based

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15

AMBA Credentials

• American Medical Billing Association (AMBA)

– CMRS: Certified Medical Reimbursement Specialist

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16

Education and Training

• Understanding HCPCS coding systems

• ICD-9-CM coding systems

• Anatomy and physiology

• Communication skills

• Human relations

• Computer applications

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17

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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18

Skills Needed

• Fee schedules

• RVUs

• CCI edits

• LMRPs

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• Excellent keyboarding skills

• Basic math skills

• In this detail oriented industry:– Typographical errors can completely

change the information provided

Skills Needed

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20

• Health insurance specialists– Review claims for completeness and

accuracy before authorizing payment or referring the claim to an investigator for a more thorough review

Skills Needed

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21

• Practice specialists – Ensure office claims report “medical

necessity” by linking CPT codes with ICD-9 codes before claims are submitted

Skills Needed

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22

Electronic Claims Submission

• Medical practices send their claims through “electronic claims processing”– Via data format or via disk– Modem– Cable– Directly to data clearinghouses or to

insurance carrier

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23

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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24

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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25

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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26

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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27

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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28

Training Requirements

• Anatomy and physiology

• Coding

• Communication

• Critical thinking

• Data entry

• Medical terminology

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29

Job Description

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

• Know all rules and regulations for major insurance programs

• Know how to post charges, payments, and adjustments to accounts

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30

Job Description

• Prepare and review claims remittance advice

• Review insurance payments

• Correct data errors and resubmit all unprocessed or returned claims

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31

Job Description

• Appeal all underpaid or denied claims

• Trace or rebill all claims not paid within 30 to 45 days

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

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32

Scope of Practice

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

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33

Qualifications

• Graduate of health insurance specialist certificate or degree program

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

• Consider certification through AAPC, AHIMA, AMBA

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34

Responsibilities

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

• Knowledge of insurance coverage, repayment issues, and health care laws and regulations

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35

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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36

Employer Insurance

• Bonding Insurance– Contract ensures repayment for financial

losses resulting from an employee’s act

• Liability Insurance– Defends business property and covers cost

of lawsuits resulting from bodily and personal injury

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37

Employer Insurance

• 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