1. Copyright © 2008 Delmar Learning. All rights reserved. Chapter 1 Health Insurance Specialist Career

2. 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.

3. Copyright © 2008 Delmar Learning. All rights reserved. 3 Opportunities Available Claims benefit advisors Coding or insurance specialists Educators in schools Writers and editors Self-employed consultants Private billing practices

4. Copyright © 2008 Delmar Learning. All rights reserved. 4 Opportunities for Insurance and Reimbursement Specialists Advisors on claims submitted – Health insurance claims – Malpractice – Liability insurance carriers

5. Copyright © 2008 Delmar Learning. All rights reserved. 5 Opportunities for Insurance and Reimbursement Specialists State, local, and Federal government agencies Legal offices Private insurance billing offices Medical societies

6. Copyright © 2008 Delmar Learning. All rights reserved. 6 Opportunities for Insurance and Reimbursement Specialists Medical practice consultants Auditors Compliance monitors

7. Copyright © 2008 Delmar Learning. All rights reserved. 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

8. Copyright © 2008 Delmar Learning. All rights reserved. 8 Overview of Role of Insurance Specialist Responsible for filing health insurance claims Handle timely reimbursement for appropriate documentation submitted

9. Copyright © 2008 Delmar Learning. All rights reserved. 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

10. Copyright © 2008 Delmar Learning. All rights reserved. 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

11. Copyright © 2008 Delmar Learning. All rights reserved. 11 Remain Current Regarding news releases from CMS Changes in industry New technology

12. Copyright © 2008 Delmar Learning. All rights reserved. 12 Professional Credentials Health insurance specialists who become members of specialized associations receive helpful information: –Professional journals –Newsletters

13. Copyright © 2008 Delmar Learning. All rights reserved. 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

14. Copyright © 2008 Delmar Learning. All rights reserved. 14 AHIMA Credentials American Health Information Management Association (AHIMA) –CCA: Certified Coding Associate –CCS: Certified Coding Specialist –CCS-P: Certified Coding Specialist- Physician-Based

15. Copyright © 2008 Delmar Learning. All rights reserved. 15 AMBA Credentials American Medical Billing Association (AMBA) –CMRS: Certified Medical Reimbursement Specialist

16. Copyright © 2008 Delmar Learning. All rights reserved. 16 Education and Training Understanding HCPCS coding systems ICD-9-CM coding systems Anatomy and physiology Communication skills Human relations Computer applications

17. Copyright © 2008 Delmar Learning. All rights reserved. 17 Skills Needed Insurance specialist positions require: –Background in word processing –Knowledge of computer applications –Anatomy and physiology –Medical terminology –Insurance claims processing

18. Copyright © 2008 Delmar Learning. All rights reserved. 18 Skills Needed Fee schedules RVUs CCI edits LMRPs

19. Copyright © 2008 Delmar Learning. All rights reserved. 19 Excellent keyboarding skills Basic math skills In this detail oriented industry: –Typographical errors can completely change the information provided Skills Needed

20. Copyright © 2008 Delmar Learning. All rights reserved. 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

21. Copyright © 2008 Delmar Learning. All rights reserved. 21 Practice specialists –Ensure office claims report “medical necessity” by linking CPT codes with ICD-9 codes before claims are submitted Skills Needed

22. Copyright © 2008 Delmar Learning. All rights reserved. 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

23. Copyright © 2008 Delmar Learning. All rights reserved. 23 Characteristics of Insurance Specialists Ability to work independently Strong sense of ethics Ability to pay attention to detail Ability to think critically

24. Copyright © 2008 Delmar Learning. All rights reserved. 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.”

25. Copyright © 2008 Delmar Learning. All rights reserved. 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.

26. Copyright © 2008 Delmar Learning. All rights reserved. 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.

27. Copyright © 2008 Delmar Learning. All rights reserved. 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

28. Copyright © 2008 Delmar Learning. All rights reserved. 28 Training Requirements Anatomy and physiology Coding Communication Critical thinking Data entry Medical terminology

29. Copyright © 2008 Delmar Learning. All rights reserved. 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

30. Copyright © 2008 Delmar Learning. All rights reserved. 30 Job Description Prepare and review claims remittance advice Review insurance payments Correct data errors and resubmit all unprocessed or returned claims

31. Copyright © 2008 Delmar Learning. All rights reserved. 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

32. Copyright © 2008 Delmar Learning. All rights reserved. 32 Scope of Practice Works with patients to make clear what their health insurance covers and their financial responsibility

33. Copyright © 2008 Delmar Learning. All rights reserved. 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

34. Copyright © 2008 Delmar Learning. All rights reserved. 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

35. Copyright © 2008 Delmar Learning. All rights reserved. 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

36. Copyright © 2008 Delmar Learning. All rights reserved. 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

37. Copyright © 2008 Delmar Learning. All rights reserved. 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