HEALTH INSURANCE SPECIALIST
MEDICAL/CODER BILLER
CAREER
THE ENGLISH CENTER
MEDICAL CODER /BILLER
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 meet the criteria for medical
necessity.
Career Opportunities
 The claims review process requires
 Verifications 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 more
thorough review
Career Opportunities
 Codding 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)
The following will be implemented on October 1, 2013
 International Classification of Diseases, 10th Revision, Clinical
Modification (ICD-10-CM)
 International Classification of Diseases, 10th Revision,
Procedural Coding System (ICD-10-PCS)
Career Opportunities
 Healthcare 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 (cont.)
 State, local, and federal government agencies
 Legal offices
 Private insurance billing offices
 Medical societies
Opportunities for Insurance and
Reimbursement Specialists (cont.)
 Medical practice consultants
 Auditors
 Compliance monitors
Opportunities for Insurance and
Reimbursement Specialists (cont.)
 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
 Handles timely reimbursement for
appropriate documentation submitted
Contracting Decisions
 Healthcare practices need to make important decisions
on signing contracts with individual insurance carriers
 Authorization requirements
 Billing deadlines
 Claims requirements
 Participating provider networks
How Does an Insurance
Specialist Stay Up-to-Date?
 Receive carrier newsletters
 Understand your contracts
 Know when they are renewed.
 Make notes on parts that are not running as
expected.
 Know your provider’s relations agent.
How Does an Insurance
Specialist Stay Up-to-Date? (cont.)
 Remain current
Regarding news releases from CMS
Regarding changes in industry
Regarding new technology
Education and Training
 HCPCS coding systems
 ICD-9-CM and ICD-10-CM and ICD-10-PCS 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 (cont.)
 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
 Internet access
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.
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 (cont.)
 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 (cont.)
 Research and appeal all underpaid or denied
claims.
 Trace all claims not paid within 30 to 45 days and
rebill if necessary.
 Notify staff and providers of any changes in
coding or documentation guidelines affecting
denials.
Job Description (cont.)
 Assist in updating practice registration and
billing forms in accordance with changes to
coding and billing requirements.
 Maintain internal audit system.
Job Description (cont.)
 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
(Medical Coder/Biller) certificate or degree
program
 Understanding of insurance billing/collection
processes
 Outstanding organizational skills and aptitude
to manage multiple tasks in a timely manner
Qualifications (cont.)
 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 healthcare laws and regulations
Responsibilities (cont.)
 Communication 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
Contract ensures repayment for financial
losses resulting from an employee’s act.
 Business liability insurance
Defends business property and covers the
cost of lawsuits resulting from bodily and
personal injury.
Professional Insurance
 Property insurance
Protects 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
 Conduct or qualities that characterize a professional person
Attitude and self-esteem
Communication
Conflict management
Customer service
Diversity awareness
Professionalism (cont.)
 Leadership
 Managing change
 Productivity
 Professional ethics
 Team building
Telephone Skills
 All healthcare team members must effectively
handle or transfer telephone calls.
Requires sensitivity to patient concerns about
healthcare problems; the healthcare
professional must communicate a caring
environment that leads to patient satisfaction.
Telephone Skills (cont.)
 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 healthcare setting.
Telephone Skills (cont.)
 Inform callers who want to speak with the
physician (or another healthcare provider)
that the physician (or provider) is with a
patient.
 Assign 15-minute time periods every two to
three hours when creating the schedule, so
physicians (and other healthcare providers)
can return telephone calls.
Telephone Skills (cont.)
 Physically separate front desk check-in/checkout 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)
Professional Associations (cont.)
 American Medical Billing Association (AMBA)
 Medical Association of Billers (MAB)