Medical Insurance Billing
What it is
What it isn’t
How it’s changing
Medical Billing is:
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Obtaining insurance information.
Verifying insurance coverage.
Making patient appointments.
Gathering medical information.
Maintaining the privacy of that information.
Transferring Diagnostic and Treatment
information into highly-specialized codes.
Medical Billing Is:
• Transferring insurance information, patient
information and coded diagnosis and
treatment information to a standard billing
form or format.
• Following up with insurers for tracking of
payments.
• Posting credits of payments made by
insurance and patients.
Medical Billling Is NOT:
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It’s not a get-rich quick scheme.
It’s not just sending invoices.
It’s not just billing the patient.
It’s not just billing one way for all insurances –
they are all different.
• It’s not usually a way to work at home unless
you already have a working relationship with a
provider or billing service. Usually jobs that can
be done at home can also be done off-shore!
Medical Billling Is NOT:
• It’s not a single class subject -- it’s a whole
curriculum of subjects.
• It’s never the same old thing!
Welcome to challenge of Medical Billing!
Be SURE you Signed the Attendance Sheet!
Once you think you know what you are doing, the
codes and the insurance rules change and you are
back in the learning curve at least once a year!
But so are all other medical billers!
This year we are introducing ICD-10-CM coding to
replace the entire ICD-9-CM code system for medical
diagnoses.
Changes to the health insurance industry related to the
Affordable Care Act (ACA or “Obamacare”) are also
implementing this year!
Subjects Covered
• Medical Information and the Law.
Confidentiality, HIPAA, Malpractice, Fraud
and Abuse.
• The medical claim cycle – appointment to
payment audit.
• Insurance Terminology, Insurance Plans.
• Medical and Financial Documentation: the
Chart Notes, the Superbill and the Ledger.
Subjects Covered
• Coding of Diagnostic information (ICD-10CM coding).
• Coding of Treatment Procedures and
Supplies (CPT and HCPCS coding).
• Completion of the CMS-1500 claim form
data elements for the X12 837P electronic
billing transaction.
Subjects Covered
• Private Insurance Plans.
• Government Health Plans (Medicare,
Medi-Cal, Tricare, ChampVA)
• Funding structures: Fee-for-service versus
Capitation.
• Provider contracts.
• Reading the Insurance Explanation of
Benefits.
Subjects Covered
• Write-off/adjustment amounts and balance
billing.
• Coordination of Benefits between multiple
insurances.
• Patient Advocacy.
• Collections.
• Job Search strategies.
Subjects Not Covered
• Medical Terminology is a required skill that is offered in
either a lecture class or a computer-based self-study
module course.
• Medical Assisting (Back-Office) is a complimentary, but
different course.
• Hospital Facility Billing is beyond the scope of a course
in physician billing. (We will, however, look at the
concepts behind facility charges and the UB-04.)
• There is no “externship” program at this school.
• Further studies in medical billing can be obtained either
at the Conejo Adult School (which has an externship
program) or at Santa Barbara City College (which has a
hospital coding program).
Books You Will Purchase:
• Medical Insurance
textbook (see the
• Course Website)
Books You Will Purchase:
• ICD-10-
CM
Books You Will Purchase:
• CPT Professional
AMA Edition
This Course IS:
• A way for beginners to learn about and
enter the field of Medical Insurance Billing.
• A way for medical billers to gain additional
skills and prepare for certification.
• A way for medical professionals to
understand the billing process.
• A way for patients and families of patients
to understand their insurance and their
rights.
About This Course:
• This isn’t a self-study course, and students
will need to attend lectures and turn off cell
phones and refrain from chatter during
lecture times.
• This isn’t a guarantee you will find a job,
but it should give you job skills. Be sure to
prepare a resume and ask about possible
externship credits.
Participation
• All students are encouraged to raise their
hands when they have personal
experiences to share or questions to ask.
• If you cannot hear your instructor, please
sit in the front row or raise your hand and
ask the instructor to speak UP!
• This is your course, make every minute
count!
Courtesy Rules
• All cell phones must be off or turned to
vibrate.
• Students may not smoke on campus.
• Questions are welcomed ONLY if a
student raises his/her hand and is
recognized before speaking.
• Cross-talking while the instructor is
lecturing or during a test is PROHIBITED.
Student Conduct
• Unexcused absences: Students will be dropped
if they have more two consecutive absences
without contacting the instructor and/or obtaining
a physician’s note.
• Students who cross-talk during class will be sent
home on second warning.
• If a student must be sent home a second time
due to cross-talking they will be dropped due to
unexcused absence.
This Course is NOT a competition!
Everybody is a winner as long as they are
courteous, attend lectures and labs, do the
projects and the homework and take the
quizzes.
Class Resources Website:
www.mediclaimclass.net
Your Instructor
Your teacher is Thomas Fitzsimmons, CPC, RHIT, NCICS
CPC= Certified Professional Coder. An credential in advanced physician
coding offered by the American Academy of Professional Coders
(AAPC.com).
RHIT= Registered Health Information Technician. A credential in medical
records technology, primarily for hospitals, offered by the American Health
Information Management Association (AHIMA.org).
NCICS= Nationally Certified Insurance and Coding Specialist. An entry-level
certification of medical insurance and coding skills offered by the National
Center for Competency Testing (NCCTinc.com). This course should
prepare you for the NCICS examination should you decide to take it.
Former Blue Cross claims examiner and appeals reviewer, provider relations
and training specialist for Transamerica, CMS contracted Medicare Part B
carrier, medical billing and coding faculty of American Career College,
Kaplan College and Simi Valley Adult School and Career Institute. Your
instructor has an associate’s degree in print journalism from Moorpark
College, a bachelor’s degree in liberal studies from Excelsior College, and
an associate’s degree in health information management from Santa
Barbara City College.
Student Introductions
Please stand up and share:
Your name?
What you would like to get out of this course
(besides just a job)?
What you would be doing if you were not
here taking this class?
Participation/Attendance
• Students who are not present for class lose
participation points. A tardy subtracts five points.
An absence subtracts 12 points, or a point for
every 15 minutes missed.
• When subtracted from an exam of 25 points this
is 25-12=13 or a score of 52% which is a failing
grade. Attendance is very important. If an
attendance is excused with a doctor’s note,
police report or death certificate, the points will
not be subtracted.
Required Materials
• Textbook and ICD/CPT books (See
instructions on class website).
• Handout materials:
– Course Calendar
– Reading Supplements
– Exercises (Coding)
Evaluations/Projects
Exams:
• Computers and Customer Service
• HIPAA Privacy Rules
• Insurance Terminology
• Medicare Program
• Diagnosis Coding
• Procedure Coding
Make-up exams are ONLY provided in the case of an
excused absence (doctor’s note, police report or death
certificate). Two unexcused absences = drop.
Extra credit is mandatory when the score on any exam is
less than 70% (i.e., -5 or more).
Student Presentation Projects
Two presentation projects are required.
Students will summarize their research
briefly for their classmates.
• Job search results: Five medical billingrelated job posts from the internet,
showing job duties, qualifications, and
hourly pay.
• Violations of HIPAA law in the news. Five
printed articles from the internet.
Job Search Questions
What kind of jobs are there for Medical Billing and related skills?
What kinds of qualifications are needed to obtain employment?
What is the pay offered for these positions?
– These are best answered by searching the internet for positions being
advertised in the local area currently. I recommend using
• www.indeed.com
Search for terms such as:
• Medical Billing
• Medical Collections
• Patient Registration
• Medical Coding
• Claims Processing
Accounts Receivable
Insurance Billing
Insurance Verification
Patient Accounts
Claims Examiner
HOMEWORK
Due next class meeting!
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Print-out five job posts (if you do not have a computer,
please research and print at Simi Valley Library or a
library near you. Printed projects may NOT be
emailed.)
Read Chapter 1, Introduction to Medical Billing Cycle.
Do the Chapter 1 “review questions” and “applying
your knowledge.”
Read Chapter 3, Patient Encounters and Billing
Information.
Do the Chapter 3 “review questions” and “applying
your knowledge.”
Bring a #2 pencil for a practice Scantron quiz on
Computers and Customer Service.