1. Health Insurance Specialist Career
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 is employed 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 Insurance and Reimbursement Specialists
Advisors on claims submitted
Health insurance claims
Malpractice
Liability insurance carriers

12. Opportunities for Insurance and 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 remittance advice
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 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

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)