1. Role of an Insurance Billing Specialist
Chapter one

2. Objectives
Responsibilities of insurance billing and coding specialists
Office procedures performed during a work day that may affect billing
Skills needed to be an accurate and efficient insurance specialist
Medical ethics and medical etiquette

3. Key Objective – Service to Patients
When choosing a career as an insurance billing specialist, match your talents to the job. An attitude directed at serving the patient’s needs should be your priority. Be alert to discover ways you can serve the patient while carrying out your job duties. A medical insurance billing specialist’s primary goal is to assist in the revenue cycle, both helping the patient in obtaining maximum insurance plan benefits and ensuring a cash flow to the health care provider….The insurance billing specialists responsibility is to conduct business in an ethical manner. Service to patients gives the opportunity to show high values, principles, and moral character, which will be appreciated and noticed (Fordney, 2012)

4. Introduction and Background

5. Background
Medical insurance professionals deal with all aspects of claims processing
Two main billing types
Facility
Hospitals, rehabilitation centers
Professional
Physicians or NPPs
The physician relies on professionals to handle coding, charge entry, submission, and follow up on claims
Facility billing is done for hospitals, acute care hospitals, skilled nursing or long-term care facilities, rehab centers. Professional billing is done for physicians or non-physician practioners.

6. Non-Physician Providers
A provider who does not have a medical degree but can prescribe medication
Should have an NPI number for claim submission
What are some examples of NPPs?
NPPs are also called physician extenders.

7. Non-Physician Providers
A provider who does not have a medical degree but can prescribe medication
Should have an NPI number for claim submission
What are some examples of NPPs?
Nurse Practitioner
Physician Assistant
Advanced Registered Nurse Practitioner
Certified Nurse Anesthetist
NPPs are also called physician extenders.

8. Payment Schedules Payment schedules are based on payer
Aka “fee schedule” or “allowable amount”
Managed care
Workers Comp
Medicare
Under Medicare, physicians are paid based on relative value units (RVU)
Payment schedules set the amount that a provider or facility can be paid for a service. Each payer has a specific payment, or fee, schedule.
Medicare’s RVU system is based on the cost, or overhead, of delivering care, the cost of malpractice insurance, and the technical skill and expertise related to the physician’s work.

9. Role of the Insurance Billing Specialist
There are many job titles assigned to someone who is responsible for billing
Billing Specialist
Electronic Claims Processor
Medical Biller
Reimbursement Specialist
Medical Billing Representative
Senior Billing Representative
Specific job titles vary depending on the region
A single billing department may have many employees that share responsibility for billing
Regardless of the title, the purpose of the job is to ensure accurate, timely charge entry, claims processing, claims follow up, and correct reimbursement.

10. Other Positions Multiskilled Health Practitioner (MSHP)
Cross-trained to perform more than one job
Claims Assistance Professional (CAP)
A patient representative assigned by CMS to help a patient understand the health insurance claim process
MSHP – knowledge of coding and claim processing
CAPs can explain provider policies and assist patients in getting the full extent of their benefits

11. Office Procedures
Procedures that may be performed during the workday in a medical office or facility
Scheduling appointments
Registering patients
Documenting patient 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.

12. The Job Itself
Job descriptions will vary by position within the medical office
Administrative professionals may be responsible for
Claims processing
Collecting payments
Informing patients of office policy
Who might be included as an Administrative Professional?
See Figure 1-1 and 1-2 for sample job descriptions.

13. Front Office Schedule appointments Register patients
Verify and enter charges
Receive payments
Why is it important to have a good report with your Front Office? – question and answer
What does the Front Office do that can impact your billing?
enter demographics
take insurance cards / scan
Charge entry – Billing Dept must review before sending out claim
Receive payments – did they collect copays, deductibles, balances?
did they call the Billing Dept for clarification on accounts?
What happens if they let a patient go without receiving monies owed?

14. Clinical Department Nurses and Medical Assistants Provide patient care
Document in the chart
Mark routers or superbills for charge entry

15. Coding / Billing Department
Verify codes
Verify insurance
Enter charges
Receive and post patient and insurance payments
Work insurance denials and aging report
Obtain authorization / precertification

16. A Little More Specific…….
Review ICD9 and CPT codes for accuracy
Collect info from hospitals, labs, and other clinicians involved in a case
Submit insurance claims promptly
Answer routine inquiries related to account balances and insurance submissions
Discuss practice financial policies with patients
Insurance coverage
Payment plans
Follow up on delinquent accounts by tracing denied, adjusted, or unpaid claims

17. Certificate Programs Medical terminology Biology
Anatomy & pathophysiology
Computer skills
Keyboarding
Word processing
Data entry
10-key adding machine
Medical insurance
Medical financial management
CPT, ICD-9-CM, HCPCS coding
English composition
Math/Algebra
Each skill learned is vital to the field of health insurance billing
Why are computer skills necessary? Why are speed and accuracy important?
Coding
Data mining

18. Medical Ethics and Liability

19. Medical Ethics and Liability Objectives
Differentiate between medical ethics and medical etiquette
Specify instances when an employer and/or employee can be liable when billing for medical services
Explain how Insurance knowledge and medical knowledge can be kept current

20. Medical Etiquette/Medical Ethics
Medical etiquette – 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, while ethics are set standards of conduct that need to be followed.
Carry out responsibilities with integrity, decency, honesty, competence, consideration, respect, fairness, trust, and courage
How many know that it takes all of these qualities to effectively interact with insurance companies, patients, other staff, and physicians?

21. AMA Principles of Medical Ethics
Physicians should be dedicated to providing competent medical service
Physicians should deal with patients and colleagues with honesty and dignity
Physicians will expose any colleague who engages in fraud or deception
Physicians shall respect the law as it relates to the practice of medicine
Are the AMA Principles of Medical Ethics actually law? - 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.

22. AMA Principles of Medical Ethics, cont’d
Physicians shall respect the right of patients within the constraints of the law
Physicians will keep up with the latest findings and medical advances to continue to provide the best possible care to patients
Except in emergency situations, physicians are free to choose where and to whom they will provide medical services
Physicians will participate in the promotion of community good will

23. AHIMA Code 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 AHIMA
AHIMA has a separate Code of Ethics, which is appropriate for those who handle health information, whether they are health information specialists, insurance billing specialists, or coders

24. AHIMA Code of Ethics, cont’d
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

25. Employer Liability
Physicians are legally responsible for staff actions
Vicarious liability
Respondeat superior – let the master answer
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. This is known as vicarious liability or respondeat superior – “let the master answer”
Insurance billers/coders should check about coverage under the physician’s malpractice insurance
Certified coders should have their own malpractice insurance

26. 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 the claim submission, you can be held responsible if there are errors
“Errors and omissions” insurance may be necessary if your are personally liable
Coders/billers MUST correct errors and document actions in writing

27. Future Challenges Know billing regulations for all payers
Know compliance rules/regulations
Know rules about patient treatment and referrals
Keep up to date with computer skills
Operating systems
Billing software
Electronic billing
Develop diagnostic and procedure coding expertise
Know how to interpret insurance documents
Attain bookkeeping skills
Stay up-to-date with industry news
Strive toward becoming certified
Continuing education

28. ANY QUESTIONS?

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