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

Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 1

Health Insurance

Specialist Career


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

Opportunities Available

• Claims benefit advisors

• Coding or insurance specialists

• Educators in schools

• Writers and editors

• Self-employed consultants

• Private billing practices


4

Opportunities for Insurance and Reimbursement Specialists

• Advisors on claims submitted– Health insurance claims– Malpractice – Liability insurance carriers


5


• State, local, and Federal government agencies

• Legal offices

• Private insurance billing offices

• Medical societies


6


• Medical practice consultants

• Auditors

• Compliance monitors


7


• Instructors for community education programs specializing in training medical billers and coders

• Textbook writers

• Newsletter writers

• Industry publications


8

Overview of Role of Insurance Specialist

• Responsible for filing health insurance claims

• Handle timely reimbursement for appropriate documentation submitted


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

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

Remain Current

• Regarding news releases from CMS

• Changes in industry

• New technology


12

Professional Credentials

• Health insurance specialists who become members of specialized associations receive helpful information:– Professional journals– Newsletters


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

AHIMA Credentials

• American Health Information Management Association (AHIMA)

– CCA: Certified Coding Associate – CCS: Certified Coding Specialist– CCS-P: Certified Coding Specialist-

Physician-Based


15

AMBA Credentials

• American Medical Billing Association (AMBA)

– CMRS: Certified Medical Reimbursement Specialist


16

Education and Training

• Understanding HCPCS coding systems

• ICD-9-CM coding systems

• Anatomy and physiology

• Communication skills

• Human relations

• Computer applications


17

Skills Needed

• Insurance specialist positions require:– Background in word processing– Knowledge of computer applications– Anatomy and physiology– Medical terminology– Insurance claims processing


18

Skills Needed

• Fee schedules

• RVUs

• CCI edits

• LMRPs


19

• Excellent keyboarding skills

• Basic math skills

• In this detail oriented industry:– Typographical errors can completely

change the information provided

Skills Needed


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

• Practice specialists – Ensure office claims report “medical

necessity” by linking CPT codes with ICD-9 codes before claims are submitted

Skills Needed


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

Characteristics of Insurance Specialists

• Ability to work independently

• Strong sense of ethics

• Ability to pay attention to detail

• Ability to think critically


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

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

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

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

Training Requirements

• Anatomy and physiology

• Coding

• Communication

• Critical thinking

• Data entry

• Medical terminology


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

Job Description

• Prepare and review claims remittance advice

• Review insurance payments

• Correct data errors and resubmit all unprocessed or returned claims


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

Scope of Practice

• Works with patients to make clear what their health insurance covers and their financial responsibility


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

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

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

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

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

Documents

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