Chapter 1
Health
Insurance Specialist Career
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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.
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© Cengage Learning 2013
Location of Code for CMS-1500
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Career Opportunities
• A claims examiner employed by a thirdparty payer reviews health-related claims to
determine whether the charges are
reasonable and meet the criteria for medical
necessity.
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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
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Career Opportunities
• A medical assistant is employed by a
provider to perform administrative and
clinical tasks that keep the office or clinic
running smoothly.
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Career Opportunities
• Coding is the process of assigning ICD-9CM 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)
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Career Opportunities
• Healthcare Common Procedure Coding System
– Current Procedural Terminology (CPT)
– HCPCS level II codes (national codes)
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Opportunities Available
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Claims benefit advisors
Coding or insurance specialists
Educators in schools
Writers and editors
Self-employed consultants
Private billing practices
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Opportunities for Insurance
and Reimbursement Specialists
• Advisors on claims submitted
– Health insurance claims
– Malpractice
– Liability insurance carriers
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Opportunities for Insurance
and Reimbursement Specialists
(cont.)
• State, local, and federal government
agencies
• Legal offices
• Private insurance billing offices
• Medical societies
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Opportunities for Insurance
and Reimbursement Specialists
(cont.)
• Medical practice consultants
• Auditors
• Compliance monitors
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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
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Overview of Role
of Insurance Specialist
• Responsible for filing health insurance
claims
• Handles timely reimbursement for
appropriate documentation submitted
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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
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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.
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How Does an Insurance
Specialist Stay Up-to-Date?
(cont.)
• Remain current
– Regarding news releases from CMS
– Regarding changes in industry
– Regarding new technology
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Education and Training
• HCPCS coding systems
• ICD-9-CM and ICD-10-CM and ICD-10PCS coding systems
• Anatomy and physiology
• Communication skills
• Human relations
• Computer applications
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Skills Needed
• Insurance specialist positions require
– Background in word processing
– Knowledge of
• Computer applications
• Anatomy and physiology
• Medical terminology
• Insurance claims processing
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Skills Needed (cont.)
– Excellent keyboarding skills
– Basic math skills
– In this detail-oriented industry
• Typographical errors can completely change the
information provided.
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Characteristics
of Insurance Specialists
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Ability to work independently
Strong sense of ethics
Ability to pay attention to detail
Ability to think critically
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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”
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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
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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
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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.
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Training Requirements
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Anatomy and physiology
Coding
Communication
Critical thinking
Data entry
Internet access
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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.
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© Cengage Learning 2013
Medical Assistant and Internship
Student Prepare for a Patient
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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.
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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.
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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.
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Job Description (cont.)
• Assist in updating practice registration and
billing forms in accordance with changes to
coding and billing requirements.
• Maintain internal audit system.
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Job Description (cont.)
• Explain benefits, policy requirements, filing
requirements, and payments to patients.
• Maintain confidentiality of patient
information.
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Scope of Practice
• Work with patients to make clear what their
health insurance covers and their financial
responsibility.
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Employer Liability
• Self-employed – Independent contractors
– Professional liability insurance
• Respondeat superior – “Let the master
answer”
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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
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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
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Responsibilities
• Knowledge of medical management
computer software to process health
insurance claims
• Knowledge of insurance coverage,
repayment issues, and healthcare laws and
regulations
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Responsibilities (cont.)
• Communication with insurance companies
and patients regarding coverage and
reimbursement issues
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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.
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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.
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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.
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Professionalism
• Conduct or qualities that characterize a
professional person
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Attitude and self-esteem
Communication
Conflict management
Customer service
Diversity awareness
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Professionalism (cont.)
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Leadership
Managing change
Productivity
Professional ethics
Team building
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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.
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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.
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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.
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Telephone Skills (cont.)
– Physically separate front desk check-in/check-out and
receptionist/patient appointment scheduling offices.
– Require office employees to learn professional
telephone skills.
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Professional Associations
• American Academy of Professional Coders
(AAPC)
• American Association of Medical
Assistants (AAMA)
• American Health Information Management
Association (AHIMA)
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Professional Associations (cont.)
• American Medical Billing Association
(AMBA)
• Medical Association of Billers (MAB)
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