1. Role of an Insurance
Billing Specialist
Chapter 1

2. Learning Objectives Lesson 1
Learning Objectives Lesson 1.1: Role of an Insurance Billing Specialist
Identify the background and importance of accurate insurance claims submission, coding, and billing.
Assess responsibilities assigned to insurance billing and coding specialists and electronic claims processors.
Name and discuss the office procedures performed during a workday that may affect billing.
Specify the educational requirements for a job as an insurance billing specialist and a coder.

3. Learning Objectives Lesson 1
Learning Objectives Lesson 1.1: Role of an Insurance Billing Specialist (Cont.)
Describe the variety of career advantages and areas of specialization open to those trained as insurance billing specialists.
List qualifications, attributes, and skills necessary to be an insurance billing specialist.
State the personal image to be projected as an insurance billing specialist.
Describe professional behavior when working as an insurance billing specialist.

4. Learning Objectives Lesson 1
Learning Objectives Lesson 1.1: Role of an Insurance Billing Specialist (Cont.)
Differentiate between medical ethics and medical etiquette.
Specify instances when an employer and/or an employee can be liable when billing for medical services.
Identify common practices and limitations of a claims assistance professional’s scope of practice to his or her clients.
Explain how insurance knowledge and medical knowledge can be kept current.

5. Background of Insurance Claims, Coding, and Billing
Medical insurance professionals deal with all aspects of claim submission.
Two main billing types
Facility billing
Hospitals, rehabilitation centers, etc.
Professional billing
Physician or non-physician practitioners (NPPs)
A physician relies on professionals to handle billing, transmission, and follow-up on claims.
Facility billing is done for hospitals, acute care hospitals, skilled nursing or long-term care facilities, rehabilitation centers, or ambulatory surgical centers.
Professional billing is done for physicians or NPPs.

6. Background of Insurance Claims, Coding, and Billing (Cont.)
Non-physician providers (NPPs)
Provider who has not obtained a medical degree and can prescribe medication
Should have a provider number for claim submission
Physician referrals to an NPP must be documented in the patient record.
Examples of an NPP: Physician assistant, nurse practitioner, advanced registered nurse practitioner, certified nurse anesthetist, physical therapist, speech therapist, licensed clinical social worker, certified registered nurse practitioner.
NPPs are also called physician extenders.

7. Background of Insurance Claims, Coding, and Billing (Cont.)
Payment schedules
Payment schedules are based on payer type.
Managed care
Workers’ compensation
Medicare
Under Medicare, physicians are paid based on relative value units (RVUs).
Payment schedules set the amount that a provider or facility can be paid for a service. Each payer has a specific payment schedule.
Medicare’s RVU system is based on: (1) the cost (overhead) of delivering care, (2) malpractice insurance, and (3) the physician’s work. This system is maintained by Centers for Medicare & Medicaid Services.

8. Background of Insurance Claims, Coding, and Billing (Cont.)
Office procedures
Procedures performed during the workday in a medical office or facility
Scheduling appointments
Registering patients
Documenting encounters
Entering charges
Filing information
Bookkeeping/accounting
Knowing the basic set-up of the medical office or facility will help you to understand how the entire organization functions and how all parts relate to reimbursement. Understanding the flow of information is vital.
A medical assistant or insurance specialist may be asked to help with all office procedures. See the textbook for more information on each area.

9. Role of the Insurance Billing Specialist
Several job titles associated with medical billing
Billing specialist
Electronic claims processor
Medical biller
Reimbursement specialist
Medical billing representative
Senior billing representative
Specific job titles may depend on the region of the U.S.
Billing department may have many employees that share responsibilities for billing, making positions more specialized.

10. Role of the Insurance Billing Specialist (Cont.)
Other positions
Multiskilled health practitioners (MSHPs)
Cross-trained to provide more than one function
Claims assistance professionals (CAPs)
Help patients organize, file, and negotiate health insurance claims of all types
MSHPs may have knowledge of claim completion and coding, to provide more flexibility to the health care provider.
CAPs can explain provider policies and assist patients in obtaining maximum benefits and explain provider policies.

11. Job Responsibilities
Job descriptions will vary for each position in a medical office.
Administrative professionals may be responsible for claims processing, collection of payments, and communicating policies to patients.
See Figures 1-1 and 1-2 for sample job descriptions.
Most medical providers will submit claims on behalf of the patient, regardless of insurance plan.
Claims should not be “rushed out the door” because there could be errors.

12. Job Responsibilities (Cont.)
Certified medical assistant role delineation chart
Table 1-1 shows the Advanced Practice of Medical Assisting Skills, with arrows indicating material covered in this text. General skills are covered in this portion of the table.
Developed by the American Association of Medical Assistants (AAMA) to show what topics must be mastered to become a certified MA.
Discuss the general skills necessary to be a certified medical assistant.

13. Job Responsibilities (Cont.)
Certified medical assistant role delineation chart
Discuss the clinical skills necessary to be a certified medical assistant, as shown in the continuation of Table 1-1.

14. Job Responsibilities (Cont.)
Certified medical assistant role delineation chart
Discuss the administrative skills necessary to be a certified medical assistant, as shown in the continuation of Table 1-1.

15. Educational and Training Requirements
Medical insurance specialist certificate program contents
Medical Terminology
Administrative Medical Office Management
Biology
Keyboarding
Computer 1
Completion of an insurance specialist certificate program at a community college is suggested to obtain a position as a medical insurance specialist.
See Figure 1-4 in the text for an example of a 1-year medical insurance specialist certification program offered at a community college.

16. Educational and Training Requirements (Cont.)
Medical insurance specialist certificate program contents
Principles and Applications of Medical Insurance
Current Issues of Medical Insurance
Medical Financial Management
Word Processing
Basic Principles of Composition
Courses may be titled or organized differently at different schools, but the topics are usually the same.
Official certification is available from professional organizations. More is discussed in Chapter 18.

17. Career Advantages Self-employment or independent contracting
Flexible hours
Disabled workers
Rehabilitation Act ensures access to information technology.
Jobs are available in a wide variety of areas (e.g., consulting firms, clinics, hospitals).
Being self-employed will mean more responsibility but could provide more flexibility.
Positions can be part time or full time, depending on the need.
Positions in this industry may appeal to a physically disabled person, depending on the job functions.

18. Qualifications and Attributes
Strong critical thinking skills
Reading skills with good comprehension
Basic mathematics
Being a logical and practical thinker
Detail oriented
Time management and social skills are equally important.

19. Skills
Solid foundation and working knowledge of medical terminology, including anatomy, physiology, disease, and treatment terms, as well as the meanings of abbreviations
Expert use of procedural and diagnostic code books and other related sources
Precise reading skills
Basic mathematics
Explain why speed and accuracy are important if you develop your own business as a medical claims and billing specialist. (The faster you become, the more money you earn. Therefore, accuracy in selecting the correct codes and speed in completing claims become marketable skills.)
In addition to these skills, personal image and behavior is important. Make sure to discuss the dress code with your supervisor and be courteous to co-workers and patients.

20. Skills (Cont.)
Knowledge of medicolegal rules and regulations of various insurance programs
Knowledge of compliance issues
Basic keyboarding and computer skills
Proficiency in accessing information through the internet
Knowledge of billing and collection techniques
Expertise in the legalities of collection on accounts
Explain why you also need to generate insurance claims with speed and accuracy.

21. Personal Image Be attentive to apparel and grooming.
Discuss appropriate dress code with the supervisor.
Consult the employer for the office policy regarding tattoos and piercings.
Discuss why fingernails should be carefully manicured and appropriate to the dress code.
Remind students that they will be in a professional environment and must present themselves as such.

22. Behavior A true professional needs to be able to:
Get along with other people.
Maintain confidentiality of patients’ medical histories and ongoing treatment.
Be a team player.
Communicate effectively.
Never take part in office gossip or politics.
It is important that all co-workers’ duties are seen as important because all co-workers are part of the team.

23. Medical Etiquette Medical etiquette Medical ethics
How medical professionals conduct themselves
Medical ethics
Standards of conduct generally accepted as moral guides for behavior
Ethics and etiquette are not the same. Etiquette is courtesy or “consideration for others,” whereas ethics are set standards of conduct that need to be followed.
Discuss electronic mail etiquette.

24. Medical Ethics AMA Principles of Medical Ethics
A physician should be dedicated to providing competent medical service.
A physician should deal with patients and colleagues with honesty and dignity and will expose any colleagues who engage in fraud or deception.
A physician shall respect the law as it relates to the practice of medicine.
Are the Principles of Medical Ethics adopted by the American Medical Association (AMA) laws? (No, they are standards of conduct that define the essentials of honorable behavior for the physician.)
It is the coder’s responsibility to inform administration or an immediate supervisor if unethical or possibly illegal coding practices are taking place.
See Box 1-1: Principles of Medical Ethics of the American Medical Association.

25. Medical Ethics (Cont.) AMA Principles of Medical Ethics
A physician shall respect the rights of patients within the constraints of the law.
A physician will keep up with the latest findings and medical advances to continue to provide the best possible care to patients.
Except in emergency situations, a physician is free to choose where and to whom he or she will provide medical services.
A physician will participate in the promotion of community good will.
See Box 1-1: Principles of Medical Ethics of the American Medical Association.

26. Medical Ethics (Cont.) AHIMA Codes of Ethics
Health information management professionals:
Respect the rights and dignity of all individuals.
Comply with all laws, regulations, and standards governing the practice of health information management.
Strive for professional excellence through self-assessment and continuing education.
Truthfully and accurately represent their professional credentials, education, and experience.
Adhere to the vision, mission, and values of the Association.
American Health Information Management Association (AHIMA) has a separate Code of Ethics, which is appropriate for persons handling health information, whether they are health information specialists, insurance billing specialists, or coders.
See Figure 1-7: AHIMA’s Code of Ethics.

27. Medical Ethics (Cont.) AHIMA Code of Ethics
Health information management professionals:
Promote and protect the confidentiality and security of health records and health information.
Strive to provide accurate and timely information.
Promote high standards for health information management practice, education, and research.
Act with integrity and avoid conflicts of interest in the performance of their professional and AHIMA responsibilities.
See Figure 1-7: AHIMA’s Code of Ethics.

28. Employer Liability
Physicians are legally responsible for staff actions.
Vicarious liability or respondeat superior
Actions of the insurance biller may have legal ramifications on the employer.
Physicians are legally responsible for their own conduct and any action of their employees performed within the context of their employment.
Respondeat superior means “let the master answer.”
Insurance billers should check about coverage under the physician’s malpractice insurance. If not, they may be personally liable.

29. Employee Liability
Billers and coders can be held personally responsible for billing errors.
“Errors and omissions” insurance is protection for errors or unintentional omissions.
Correct any errors and document in writing.
If you are involved in any part of claim submission, you can be held responsible if there are errors.
“Errors and omissions” insurance may be necessary if the biller/coder is personally liable.
Coders/billers must correct errors and document actions in writing.

30. Scope of Practice Claims assistance professional (CAP)
Informal representative of patients
Assists in obtaining reimbursement
Legal ability is limited
May need license
Certain states require CAPs to be licensed. Even with a license, a CAP is not a lawyer.
Alliance of Claims Assistance Professionals (ACAP) represents CAPs and can help with questions about licensing, liability, and insurance.

31. Future Challenges Know billing regulations for all payers.
Know aspects of compliance rules and regulations.
State rules about patient treatment and referrals.
Be proficient in computer skills.
Learn electronic billing software for each payer.
Develop diagnostic and procedure coding expertise.
Each of these future challenges will make you a better insurance biller.

32. Future Challenges (Cont.)
Know how to interpret insurance documents.
Attain bookkeeping skills to manage patient/practice accounts.
Stay up to date with industry news.
Cross-train in areas of practice management.
Strive toward becoming certified and seek continuing education.
All of these challenges will make you more effective.

33. Questions?