HEALTH INSURANCE SPECIALIST MEDICAL/CODER BILLER CAREER

1. HEALTH INSURANCE SPECIALIST MEDICAL/CODER BILLERCAREER THE ENGLISH CENTER MEDICAL CODER /BILLER

2. 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.

3. 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.

4. 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

5. 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)

6. Career Opportunities • Healthcare Common Procedure Coding System • Current Procedural Terminology (CPT) • HCPCS level II codes (national codes)

7. Opportunities Available • Claims benefit advisors • Coding or insurance specialists • Educators in schools • Writers and editors • Self-employed consultants • Private billing practices

8. Opportunities for Insurance and Reimbursement Specialists • Advisors on claims submitted • Health insurance claims • Malpractice • Liability insurance carriers

9. Opportunities for Insurance and Reimbursement Specialists (cont.) • State, local, and federal government agencies • Legal offices • Private insurance billing offices • Medical societies

10. Opportunities for Insurance and Reimbursement Specialists (cont.) • Medical practice consultants • Auditors • Compliance monitors

11. 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

12. Overview of Role of Insurance Specialist • Responsible for filing health insurance claims • Handles timely reimbursement for appropriate documentation submitted

13. 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

14. How Does an InsuranceSpecialist 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.

15. How Does an Insurance Specialist Stay Up-to-Date? (cont.) • Remain current • Regarding news releases from CMS • Regarding changes in industry • Regarding new technology

16. 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

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 (cont.) • Excellent keyboarding skills • Basic math skills • In this detail-oriented industry • Typographical errors can completely change the information provided.

19. Characteristics of Insurance Specialists • Ability to work independently • Strong sense of ethics • Ability to pay attention to detail • Ability to think critically

20. 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”

21. 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

22. 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

23. 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.

24. Training Requirements • Anatomy and physiology • Coding • Communication • Critical thinking • Data entry • Internet access

25. 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.

26. 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.

27. 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.

28. 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.

29. Job Description (cont.) • Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements. • Maintain internal audit system.

30. Job Description (cont.) • Explain benefits, policy requirements, filing requirements, and payments to patients. • Maintain confidentiality of patient information.

31. Scope of Practice • Work with patients to make clear what their health insurance covers and their financial responsibility.

32. Employer Liability • Self-employed - Independent contractors • Professional liability insurance • Respondeat superior – “Let the master answer”

33. 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

34. 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

35. Responsibilities • Knowledge of medical management computer software to process health insurance claims • Knowledge of insurance coverage, repayment issues, and healthcare laws and regulations

36. Responsibilities (cont.) • Communication with insurance companies and patients regarding coverage and reimbursement issues

37. 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.

38. 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.

39. 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.

40. Professionalism • Conduct or qualities that characterize a professional person • Attitude and self-esteem • Communication • Conflict management • Customer service • Diversity awareness

41. Professionalism (cont.) • Leadership • Managing change • Productivity • Professional ethics • Team building

42. 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.

43. 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.

44. 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.

45. 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.

46. Professional Associations • American Academy of Professional Coders (AAPC) • American Association of Medical Assistants (AAMA) • American Health Information Management Association (AHIMA)

47. Professional Associations (cont.) • American Medical Billing Association (AMBA) • Medical Association of Billers (MAB)