Health Insurance Specialist Career Chapter 1 Health Insurance Specialist Career

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

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.

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.

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.

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

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

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)

Career Opportunities Health Care 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 Insurance and Reimbursement Specialists Advisors on claims submitted Health insurance claims Malpractice Liability insurance carriers

Opportunities for Insurance and Reimbursement Specialists State, local, and Federal government agencies Legal offices Private insurance billing offices Medical societies

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

Opportunities for Insurance and Reimbursement Specialists 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 Handle timely reimbursement for appropriate documentation submitted

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

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

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

Education and Training Understanding HCPCS coding systems ICD-9-CM 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 Anatomy and physiology Medical terminology Insurance claims processing

Skills Needed 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 Anatomy and physiology Coding Communication Critical thinking Data entry

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.

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 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

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

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

Job Description 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 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 health care laws and regulations

Responsibilities Communicate 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 Business Liability 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

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

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

Professionalism Leadership Managing change Productivity Professional ethics Team building

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

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

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.

Telephone Skills 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) American Medical Billing Association (AMBA)

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