Chapter 1. Health Insurance Specialist Career

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1 Chapter 1 Health Insurance Specialist Career

2 INTRODUCTION Health insurance practice follow rules of the health insurance policy. The office staff or the insurance specialist work hard to send bills on time to insurance company for payment. Health insurance specialists are responsible for medical coding, maintaining patient records, and processing Health Insurance Claims. 2

3 Health Insurance Overview Health Insurance Claim documentation submitted to an insurance plan requesting reimbursement for health-care service provided. Preauthorization/prior approval may be required. If preauthorization is not met the claim could be denied resulting in a Hold Harmless Clause, which is a policy that the patient is not responsible for paying what the insurance plan denies. 3

4 Health Insurance Overview Balance Billing Billing beneficiaries for amounts not reimbursed by payer (not including copayments & coinsurance amounts). This practice is prohibited by Medicare regulations. Managed Care contracts are signed by Health care Providers: Each have different set of requirements, billing deadlines, claims deadline requirement Providers must comply with rules/regulation of each contract signed. 4

5 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 5

6 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. Remain current Regarding news releases from CMS Regarding changes in industry Regarding new technology 6

7 Health Insurance Overview Center for Medicare & Medicaid services (CMS) formerly known as Health Care Financing Administration (HCFA); an administration agency within the federal Department of Health & Human Services (DHHS) 7

8 Health Insurance 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. 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. 8

9 Medical Necessity Example Medical Necessity require linking procedure code or service codes to a condition code that justifies the need to perform that procedure or service. 9

10 Health Insurance Career Opportunities After Medical Necessity has been established, the claims review process began, which 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 10

11 Health Insurance Career Opportunities A Medical Assistant is employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly. Responsible for filing health insurance claims Handles timely reimbursement for appropriate documentation submitted 11

12 Health Insurance Career Opportunities Coding 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) A coding system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters, as well as inpatient procedures & services. 12

13 Health Insurance Career Opportunities The scheduled for implementation on October 1, 2015 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) A coding system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters, such as annual physical examination performed at the physician office). International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) - A coding system used to report procedures & services on inpatient hospital claims 13

14 Health Insurance Career Opportunities Healthcare Common Procedure Coding System (HCPCS) consist of two levels: 1. Current Procedural Terminology (CPT) Coding system published by American Medical Association (AMA) used to report: Procedures & Services performed during outpatient and physician office encounters Professional services provided to inpatients 2. HCPCS Level II Codes (national codes) A coding system published by CMS that is used to report procedures, services & supplies not in the CPT 14

15 Health Insurance Career Opportunities/Other Settings Claims benefit advisors Coding or insurance specialists Educators in schools Writers and editors Self-employed consultants Private billing practices 15

16 Health Insurance Career Opportunities Other Settings Advisors on claims submitted Health insurance claims Malpractice Liability insurance carriers 16

17 Health Insurance Career Opportunities Other Settings Coding or Insurance Specialist in State, Local, and federal government agencies Legal offices Private insurance billing offices Medical societies Medical practice consultants Auditors Compliance monitors 17

18 Health Insurance Career Opportunities Other Settings Instructors for community education programs specializing in training medical billers and coders Textbook writers Newsletter writers Industry publications 18

19 Education and Training HCPCS Coding Systems ICD-9-CM, ICD-10-CM & ICD-10-PCS Coding Systems Anatomy and Physiology Communication Skills Human Relations Computer Applications Insurance Claims Processing 19

20 Education and Training (cont.) Excellent Keyboarding Skills Basic Math Skills In this detail-oriented industry Typographical errors can completely change the information provided. 20

21 Characteristics of Insurance Specialists Ability to work independently Strong sense of Ethics Ability to pay attention to detail Ability to think Critically 21

22 Definition of Ethics The American Heritage Concise Dictionary The principles of right or good conduct, and rules that govern the conduct of members of a profession 22

23 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 23

24 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 24

25 Communication Skills Needed Written Communication skills are needed when preparing effective appeals for unpaid claims. Critical Thinking "is the identification and evaluation of evidence to guide decision making. A critical thinker uses broad in-depth analysis of evidence to make decisions and communicate his/her beliefs clearly and accurately." 25

26 Training Requirements Anatomy - study of internal and external structures of the body and the relationships between body parts. Physiology study of how living organisms perform their vital functions 26

27 Training Requirements Medical Terminology is a system of words that are used to describe specific medical aspects and diseases. It is based on standard root words, prefixes, and suffixes. Pharmacology - the science of drugs, including their composition, uses, and effects. 27

28 Training Requirements Diagnosis & Procedure Service Coding ICD-9-CM & ICD-10-CM Coding International classification of disease 9 th or 10 revision Physician s Diagnoses Procedural Coding System (PCS) Hospital Procedures CPT - Procedural coding system Physician s Procedures Communication Good oral & written communications skills. 28

29 Training Requirements Critical Thinking - a way of deciding whether a claim is always true, sometimes true, partly true, or false. Make a distinction decision on code description A critical thinker uses broad in-depth analysis of evidence to make decisions and communicate his/her beliefs clearly and accurately. (Webster) Data Entry Carefully & accurately enter data about the patient's care Internet Access Online access to medical references, Insurance company manuals, and procedure guidelines. 29

30 Student Internship An 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. 30

31 Job Description Health Insurance Specialist 1. Analyze documentation and code all diagnoses, procedures, and services. 2. Know all rules and regulations for major insurance programs. 3. Accurately post charges, payments, and adjustments to accounts. 31

32 Job Description (cont.) 4. Prepare and review claims generated to ensure accuracy and expedite reimbursement. 5. Review insurance payments and remittance advice. 6. Correct data errors and resubmit all unprocessed or returned claims. 32

33 Job Description (cont.) 7. Research and appeal all underpaid or denied claims. 8. Trace all claims not paid within 30 to 45 days and rebill if necessary. 9. Notify staff and providers of any changes in coding or documentation guidelines affecting denials. 33

34 Job Description (cont.) 10. Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements. 11. Maintain internal audit system. 34

35 Job Description (cont.) 12. Explain benefits, policy requirements, filing requirements, and payments to patients. 13. Maintain confidentiality of patient information. 35

36 Scope of Practice & Employer Liability Health care Specialist work with patients to make clear what their health insurance covers and their financial responsibility. 36

37 Scope of Practice/Employer Liability Independent Contractors (self-employed) performs services for another under an express or implied agreement who is not subject to the other's control, or right to control, of the manner and means of performing the service. 37

38 Scope of Practice & Employer Liability Independent Contractor must purchase Professional Liability Insurance or Errors and Omission Insurance Errors & Omission Insurance Policy Provides individual protection against loss of monies that occurs through error or unintentional omission on the part of individual or service submitting the insurance claim. 38

39 Scope of Practice & Employer Liability Health Care Facilities/Physician are legally responsible for the actions of the people that they hire which is called: Respondeat Superior means Let the master answer 39

40 Scope of Practice/Profession Profession one who interacts with patients to clarify health insurance coverage and financial responsibility, completes & process insurance claims, & appeals denied claims. 40

41 Scope of Practice/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 41

42 Scope of Practice/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 42

43 Scope of Practice/Responsibilities Knowledge of medical management computer software to process health insurance claims Knowledge of insurance coverage, repayment issues, and healthcare laws and regulations Communication with insurance companies and patients regarding coverage and reimbursement issues 43

44 Scope of Practice/ 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. 44

45 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. 45

46 Employer 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. 46

47 Professionalism Conduct or qualities that characterize a professional person Attitude & Self-Esteem Attitude impacts ones ability to perform job function positive or negative. Self-Esteem Low/lack of confidence or High/high confidence "For success, attitude is equally as important as ability" - Harry F. Banks 47

48 Professionalism Communication Self-expression & active listening to develop understanding about what others are saying. "And he goes through life, his mouth open, and his mind closed." - William Shakespeare Conflict Management - Part of a decision making process can be handled positively or negatively. "When angry, count to 10 before you speak; if very angry, a hundred." Thomas Jefferson 48

49 Professionalism Customer Service Health Insurance Specialist serve as direct contact for a provider s patients. "If we don't take care of our customers, someone else will." - Unknown Diversity awareness Develop tolerance & understanding for the difference among people of other ethnic backgrounds. "The real death of America will come when everyone is alike." - James T. Ellison 49

50 Professionalism (cont.) Leadership The ability to manage, motivate and delegate "The difference between a boss and a leader: a boss says, 'Go' and a leader says, 'Lets go!'" - E.M. Kelly Managing Change Necessary to implement new and revised program (nothing stays the same). "If we don't change, we don't grow, we aren't really living." - Gail Sheehy 50

51 Professionalism (cont.) Productivity Stay current, obtain certification, increase job knowledge. "Even if you are on the right track, you'll get run over if you just set there." - Will Rogers Professional Ethics Ability to work independently, attention to detail, ability to think critically, and a strong sense of ethics. "Always do right this will gratify some and astonish the rest." - Mark Twain 51

52 Professionalism (cont.) Team building Sharing leadership role and working together to complete difficult tasks facilitates team-building. Provide help to, and receive help from other team members. "Michael, if you can't pass, you can't play." - Coach Dean Smith to Michael Jordan in his freshmen year 52

53 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. 53

54 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. 54

55 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. 55

56 Telephone Skills (cont.) Physically separate front desk check-in/checkout and receptionist/patient appointment scheduling offices. Require office employees to learn professional telephone skills. 56

57 57

58 Sections Chapter Found Medical Terminology Med Term - Class Anatomy and Physiology A&P Class Web and Information Technology Internet Research ICD-9-CM Coding Chapter 6 CPT-4 Coding Chapter 7 & 8 Clearinghouses Chapter 4 CMS 1500 Chapter 4, Chapter 11 Insurance Chapter 1, 2, 9 & Insurance Carriers Chapter 11, 12, 13, 14, 15, 16, & 17 Acronyms Thru out Textbook Compliance Chapter 5 Fraud and Abuse Chapter 5 Managed Care Chapter 3 General Thru out Textbook Chapter 10, & Appendix I, II Case Study 58

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