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2 A Guide to Health Insurance Billing, Third Edition Marie A. Moisio Vice President, Career and Professional Editorial: Dave Garza Director of Learning Solutions: Matthew Kane Senior Acquisitions Editor: Rhonda Dearborn Managing Editor: Marah Bellegarde Product Manager: Jadin Babin-Kavanaugh Editorial Assistant: Lauren Whalen Vice President, Career and Professional Marketing: Jennifer Baker Marketing Director: Wendy Mapstone Senior Marketing Manager: Nancy Bradshaw Marketing Coordinator: Erica Ropitzky Production Director: Carolyn Miller Production Manager: Andrew Crouth Senior Content Project Manager: Kenneth McGrath Senior Art Director: Jack Pendleton Technology Product Manager: Mary Colleen Liburdi Technology Project Manager: Brian Davis 2011, 2006, 2001 Delmar, Cengage Learning ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may be reproduced, transmitted, stored, or used in any form or by any means graphic, electronic, or mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior written permission of the publisher. For product information and technology assistance, contact us at Cengage Learning Customer & Sales Support, For permission to use material from this text or product, submit all requests online at Further permissions questions can be ed to Current Procedural Terminology (CPT) 2009 American Medical Association. All Rights Reserved. Library of Congress Control Number: ISBN-13: ISBN-10: Delmar 5 Maxwell Drive Clifton Park, NY USA Cengage Learning is a leading provider of customized learning solutions with office locations around the globe, including Singapore, the United Kingdom, Australia, Mexico, Brazil, and Japan. Locate your local office at: international.cengage.com/region Cengage Learning products are represented in Canada by Nelson Education, Ltd. To learn more about Delmar, visit Purchase any of our products at your local college store or at our preferred online store Notice to the Reader Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities described herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. The publisher makes no representations or warranties of any kind, including but not limited to, the warranties of fitness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers use of, or reliance upon, this material. Printed in the United States of America

3 CHAPTER 1 The Insurance Billing Specialist LEARNING OBJECTIVES Upon successful completion of this chapter, the reader should have the knowledge to: 1. Describe at least 10 responsibilities of an insurance billing specialist. 2. Identify at least five personal qualifications and five technical qualifications associated with insurance billing specialist positions. 3. Provide three examples that illustrate the importance of medical terminology to insurance billing activities. 4. Describe five different job opportunities related to the insurance billing process. KEY TERMS American Academy of Professional Coders (AAPC) American Health Information Management Association (AHIMA) American Medical Billing Association (AMBA) Certification Certified coding assistant (CCA) Certified coding specialist (CCS) Certified coding specialist physician-based (CCS-P) Certified healthcare reimbursement specialist (CHRS) Certified medical billing specialist (CMBS) Certified medical billing specialist hospital (CMBS-H) Certified medical reimbursement specialist (CMRS) Certified professional coder (CPC) Certified professional coder hospital (CPC-H) Certified professional coder payer (CPC-P) Claims assistance professional (CAP) Insurance billing specialist Insurance collection specialist Insurance counselor Medical Association of Billers (MAB) Medical coder Medical coding Medical terminology National Electronic Billers Alliance (NEBA) Patient account representative Personal qualifications Technical qualifications 1

4 2 A GUIDE TO Health Insurance Billing OVERVIEW The health care industry offers employment opportunities in many different specialities. Most people know about clinical career choices, such as medicine, nursing, physical therapy, medical assisting, physician s assistant, and other patient-contact jobs. Although these professions are highly visible, the health care industry relies on a large nonclinical workforce, which is collectively known as support staff. As the name implies, the support staff assists not only the clinical staff but also the health care industry as a whole. The health care industry is somewhat like an iceberg: Clinical jobs represent the tip of the iceberg, and support staff jobs represent the rest of the iceberg. Figure 1 1 illustrates some job titles for support staff employees. The position of each title does not reflect the importance or value of the profession. This book focuses on the roles and responsibilities of the insurance billing specialist, and this chapter serves as an introduction to the insurance billing specialist. INSURANCE BILLING SPECIALIST An insurance billing specialist is as an individual who processes health insurance claims in accordance with legal, professional, and insurance company guidelines and regulations. As part of the health care industry, insurance billing specialists work closely with the financial and managerial areas of a health care agency. The insurance billing specialist is a key player in the financial operations of an agency or medical office. Tasks assigned to an insurance billing specialist can range from collecting patient insurance information to resolving billing problems between the office, patient, and insurance company. Regardless of the responsibilities associated with insurance billing, anyone who works in this dynamic field must possess certain personal and technical qualifications. Both types of qualifications are important, and the degree of emphasis placed on each depends on the individual employer. Physician Nurse Therapist Clinical Staff Support Staff Office Manager Insurance Billing Specialist Medical Coder Medical Secretary Delmar/Cengage Learning Unit Coordinator Medical Record Clerk Receptionist Transcriptionist File Clerk FIGURE 1 1 Support Staff Job Titles

5 The Insurance Billing Specialist 3 Personal Qualifications Personal qualifications are those behaviors that define the character or personality of an individual. Personal qualifications include terms such as aggressive, aloof, assertive, cooperative, ethical, hardworking, reliable, and self-motivated. These qualifications are difficult to measure and are often based on an observer s interpretation. Qualities you identify as assertive and hardworking could be considered by others as aggressive. Employers try to quantify personal qualifications by describing behaviors that exemplify the qualification. For example, cooperative describes the ability to work with others; assertive relates to the ability to communicate with others; reliable measures one s attendance and ability to complete tasks; ethical characterizes one s ability to maintain confidential information and adhere to rules and regulations. These types of descriptions are part of (or should be part of) the job description. Personality inventory tests can identify personal qualifications. A personality inventory is exactly what the name implies: a series of questions designed to identify aspects of an individual s personality or personal characteristics. Personality inventory tests have become a routine part of the employment application process. The highest-rated personal qualifications as identified by office managers and personnel directors include assertiveness/confidence, honesty, and reliability. For insurance billing specialist positions, employers seek individuals who are ethical, self-motivated, detail-oriented, able to maintain confidential information, and capable of adapting to change. Table 1 1 lists key personal qualifications and examples of behaviors that demonstrate each qualification. Table 1 1 Personal Qualifications Personal Qualification Adaptable Assertive; confident Cooperative Detail-oriented Ethical Honest Maintains confidentiality Reliable Self-motivated Behavioral Examples Accepts shift and holiday rotation schedule; willing to learn new software features; interested in cross-training Speaks clearly with eye contact; asks questions; describes goals; answers questions directly Works or has worked on group projects; interested in learning overall office workflow Accurately alphabetizes a list of names; accurately organizes a list of numbers; accurately completes health insurance billing forms Adheres to insurance billing guidelines; refrains from negative comments about current and previous coworkers and employers Leaves office supplies at the office; uses sick time according to agency policy Maintains professional confidences (i.e., patient information); does not contribute to rumors or gossip Is ready to work at the beginning of the shift; completes tasks within assigned deadlines Initiates work assignments; organizes work area

6 4 A GUIDE TO Health Insurance Billing Most people believe they are honest, reliable, ethical, and able to maintain confidentiality. Assessing your ability to adapt to change and your attention to detail is more difficult. Professional, legal, and insurance company regulations that govern health insurance billing practices are continually revised. A simple clerical or data entry oversight might delay or deny payments for services provided. Success as an insurance billing specialist depends on the ability to accurately complete and submit insurance claims. REINFORCEMENT EXERCISES 1 1 Write the name of the personal qualification described in each statement. 1. Olivia is at her desk and ready to tackle her assignments when the workday begins. 2. Linda refuses to answer her fiancé s questions about his boss, a recent patient at Linda s office. 3. Brian tells his supervisor that he used the wrong insurance code on the claims he sent out yesterday. 4. Tawanda calls Dr. Shaski and asks for clarification concerning the diagnosis for Mrs. Gervais. 5. Hank reviews the new instructions for electronic claims submission before submitting Medicare insurance claims. 6. Monroe reviews Mrs. Mattson s insurance form and discovers that vasectomy follow-up was noted as the reason for the office visit. He flags the insurance form for determination of the correct reason for Mrs. Mattson s office visit.

7 The Insurance Billing Specialist 5 Technical Qualifications Technical qualifications are measurable abilities and skills that one can learn through education and experience. Basic skills include the ability to keyboard (data entry), read, complete simple math functions, use correct grammar in written and oral communications, accurately record telephone or voice mail messages, and follow directions. Table 1 2 lists these basic skills and application examples. In addition to basic skills, the insurance billing specialist must have a working knowledge of medical terminology and be familiar with medical coding protocols. Virtually all financial aspects of a medical practice depend on thorough documentation of the patient s condition and accurate medical coding of diagnostic and treatment terms. Medical terminology is the language of the health care industry. A working knowledge of medical terminology is more than memorizing lists of words. The insurance billing specialist must be able to: Read and understand medical reports. Recognize the relationship between diagnostic statements and treatments provided. Identify discrepancies in medical documentation. Example A illustrates the ability to recognize the relationship between diagnostic statements and the treatments provided. Example B illustrates the ability to identify discrepancies in medical documentation. EXAMPLE A The diagnosis and subsequent treatment of strep throat should be supported by a throat culture test result that identified the streptococcus bacteria. EXAMPLE B The diagnosis prostatitis (inflammation of the prostate gland) should not appear in the medical record of a female patient. Table 1 2 Technical Qualifications Technical Qualification Data entry (keyboarding) Documenting messages Math skills Oral communication skills Ability to follow directions Written communication skills Application Examples Updates computerized patient records and financial and insurance records Retrieves voice mail messages; accurately takes and routes telephone messages Updates patient accounts; calculates charges for billing; reconciles amount paid with amount owed Answers questions and telephone inquiries by using complete sentences and correct grammar Reviews and implements new procedures related to insurance billing tasks Formats memos; composes letters, fax, and messages; uses correct grammar, punctuation, and spelling

8 6 A GUIDE TO Health Insurance Billing Medical coding is the process of documenting medical information as numeric codes. Two major coding systems apply to medical information: the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT). Chapters 4 and 5, respectively, discuss these two coding systems. Both coding systems are revised annually. The insurance billing specialist must keep current with coding practices. This is accomplished by attending workshops, seminars, and other continuing education (CE) events. Insurance billing specialists and medical coders who are certified by a professional association are often required to attain a specific number of CE credits within a given time frame. Failure to fulfill CE requirements may lead to the revocation of credentials and the loss of employment. REINFORCEMENT EXERCISES 1 2 Write the name of the technical qualification described in each statement. 1. Martha entered patient insurance files into the financial database. 2. Roger completed several letters of inquiry and sent them to different insurance companies. 3. Lisa s first job every morning is to scan the office voice mail system for priority messages. 4. Per office policy, Rosa updates her insurance billing manual as soon as she receives new guidelines. 5. Lucy provided Mrs. Washington with an estimate of her out-of-pocket expenses for her scheduled mammography. EMPLOYMENT OPPORTUNITIES Employment opportunities in the medical insurance billing field range from hourly entry-level billing clerk positions to five-figure management positions. Jobs are available in medical offices, hospitals, clinics, insurance companies, government agencies, medical suppliers, and consulting

9 The Insurance Billing Specialist 7 firms. An insurance billing specialist with extensive experience can own and operate a successful insurance claim processing business. Figure 1 2 is a generic job description for an insurance billing specialist. JOB DESCRIPTION POSITION TITLE: Insurance Billing Specialist SUMMARY: Accurately completes and submits health insurance claims following legal, professional, and insurance company guidelines. The work is detail-oriented, repetitive, and involves extensive communication with others. RESPONSIBILITIES: The listed responsibilities are intended to be representative rather than all-inclusive. 1. Abstracts identification, health insurance plan, and diagnoses and treatment information from the patient record. 2. Uses abstracted information to accurately complete health insurance claim form(s). 3. Follows applicable coding conventions to accurately assign numeric codes to each diagnosis and treatment statement. 4. Reviews policy and guideline bulletins (updates) from health insurance companies and organizations. 5. Applies updated regulations and guidelines to all insurance claim completion activities. 6. Monitors denied or rejected claims to identify the clerical mistakes or clinical omission that generated the rejection. 7. Notifies clinical and support staff of changes in insurance regulations and guidelines that affect documentation of patient information and insurance billing procedures. 8. Assists clinical and support staff in resolving documentation problems related to insurance claims. 9. Posts insurance payments and adjustments to patients financial records. 10. Keeps patient information confidential. 11. Adheres to office policy and procedures related to work attendance, breaks, vacation, and sick leave. MINIMUM QUALIFICATIONS 1. High-school diploma, or equivalent, and one year experience as an insurance billing specialist OR graduate of an insurance billing specialist education program. 2. Demonstrated knowledge of medical terminology, including names of diseases, clinical procedures, basic anatomy, and physiology. 3. Keyboarding skills, including data entry, updating databases, word processing, and other related skills. 4. Familiarity with at least one major word-processing software program, such as Microsoft Word or WordPerfect. 5. Ability to work cooperatively and independently as necessary. DESIRABLE QUALIFICATIONS 1. Demonstrated knowledge of current procedural and diagnostic coding conventions. 2. Certified Medical Billing Specialist (CMBS) or Certified Medical Reimbursement Specialist (CMRS) credentials. Delmar/Cengage Learning FIGURE 1 2 Insurance Billing Specialist Job Description

10 8 A GUIDE TO Health Insurance Billing Job titles such as billing clerk, medical biller, insurance claims processor, and reimbursement specialist are sometimes used in place of insurance billing specialist. Larger group practices and hospital billing departments often employ individuals who specialize in specific types of health insurance billing. EXAMPLE Segway Physicians, Inc., a 15-physician group practice, has a large insurance billing department. The department includes a Medicare billing specialist, a Medicaid billing specialist, and a Blue Cross/Blue Shield billing specialist. These specialists develop insurance billing expertise in their assigned areas. Other job opportunities related to the insurance billing process include: Claims assistance professional (CAP): He or she assists patients in completing the paperwork necessary to obtain insurance payments. Claims assistance professionals can work for health care agencies or operate their own businesses. Insurance collection specialist: He or she works with insurance companies to resolve billing and payment problems. Patient account representative: He or she helps the patient identify the amount that health insurance pays for a given service and how much the patient must pay. A patient account representative is also called an insurance counselor. Medical coder: He or she assigns numeric codes to diagnostic, procedure, and treatment information. Health insurance billing positions have a common group of responsibilities and tasks in addition to the specific duties associated with the individual position. Common tasks and responsibilities for all positions include the ability to: Abstract information from patient records. Communicate via fax, , telephone, letters, and memos. Demonstrate an understanding of insurance billing legal and ethical issues. Follow office policies and procedures. Maintain a positive working relationship with patients, staff, and visitors. Operate word-processing equipment. Participate in continuing education activities. Specific duties related to each health insurance billing position depend on the job and employer preference. Table 1 3 lists each position and gives examples of additional responsibilities for that position. In addition to the specific duties listed in Table 1 3, each health insurance billing position is associated with a particular employment setting. Claims assistance professionals usually work directly for the client or patient and are often self-employed. Insurance collection specialists usually work for medium-to-large health care agencies, such as physician group practices or hospitals. These specialists represent the interest of the health care agency when any problems with insurance payments occur. Patient account representatives, who are employed by large multispecialty clinics or hospitals, work to establish payment options before services are provided.

11 The Insurance Billing Specialist 9 Table 1 3 Insurance Billing Position Responsibilities Position Claims assistance professional Insurance collection specialist Patient account representative Responsibilities Helps individuals, clients, or patients submit medical bills to insurance companies Explains the content of insurance company documents to the client, individual, or patient Communicates with medical office and insurance company staff on behalf of the client Works with patients, insurance companies, and employer health benefits representatives to resolve insurance billing and/or payment problems Reviews insurance forms to identify patterns of errors that result in unpaid or rejected claims Monitors medical coding accuracy Provides insurance form completion training to medical office staff Maintains knowledge of regulations related to insurance collection practices Discusses insurance coverage with the patient Contacts the insurance company to verify the patient s eligibility and the amount to be paid by insurance Helps establish a payment plan for the patient REINFORCEMENT EXERCISES List three job titles that are synonymous with insurance billing specialist. 2. The helps clients complete the paperwork necessary to obtain insurance payments for medical bills. 3. Melinda met with the in order to find out the amount insurance would pay for her impending surgery. continued on the next page

12 10 A GUIDE TO Health Insurance Billing continued from the previous page 4. List three minimum qualifications that are often listed on an insurance billing specialist job description. 5. Identify five common tasks associated with insurance billing positions. EDUCATIONAL, CERTIFICATION, AND CAREER OPPORTUNITIES Medical insurance billing has become increasingly complex, and most employers now require successful completion of some kind of formal education. Insurance billing specialist programs include courses such as medical terminology, anatomy and physiology, medical insurance processing, medical coding, word processing, and English. These programs are usually between one and two years long. A one-year program is known as a certificate or diploma program, and a two-year program usually results in an associate degree. These programs allow you the opportunity to acquire the technical qualifications discussed earlier in this chapter. Certification is a process that involves successful completion of a professionally recognized exam. Employers know that education and/or experience are needed to pass national or professional exams. Professional credential exams are viewed as objective measures of an individual s expertise in a given field. Several professional associations offer certification or credentialing exams related to medical billing and medical coding. Table 1 4 lists the name and website of medical billing professional associations, the exams offered by the association, the requirements to take the exam, and the title associated with successful completion of the exam. The exams include questions related to insurance billing, medical terminology, and medical coding. Certification specifically related to medical coding significantly increases career opportunities for an insurance specialist. Table 1 5 lists the name and website of professional associations that offer medical coding certification exams, the requirements to take the exam, and the title associated with successful completion of the exam. Each professional association s website has the most current information about credentials, certification exams, and member services. Career opportunities differ from employment opportunities in that the word career brings to mind professional growth and development. A career ladder or career path indicates that the individual is moving toward a higher goal. Advancement along a career path is accompanied by an increase in status, responsibility, and pay. Career advancement is accomplished through acquiring additional education and experience. Once career goals are met, the individual must stay current in all aspects of his or her chosen field.

13 The Insurance Billing Specialist 11 Table 1 4 Medical Billing Certification Exams Professional Association American Medical Billing Association (AMBA): www. ambanet.net Medical Association of Billers (MAB): www. physicianswebsites.com National Electronic Billiers Alliance (NEBA): www. nebazone.com Certification Exams Certified Medical Reimbursement Specialist (CMRS): Individuals with medical billing experience in various health care settings Certified Medical Billing Specialist (CMBS): Individuals currently working in a medical office, a health insurance company, or an insurance billing agency; an entry-level billing and coding exam Certified Medical Billing Specialist-Chiropractic Assistant (CMBS-CA): Individuals working in a chiropractic agency; an intermediate level exam Certified Medical Billing Specialist-Hospital (CMBS-H): Individuals working in a hospital; an intermediate-level exam covering the differences between inpatient and outpatient billing Certified Healthcare Reimbursement Specialist (CHRS): Individuals with experience in all areas of the medical billing profession Table 1 5 Medical Coding Certification Exams Professional Association American Academy of Professional Coders (AAPC): American Health Information Management Association (AHIMA): org Certification Exams Certified Professional Coder (CPC): Current experience working in home health, ambulatory surgery centers, physician office or group practice; associated degree recommended Certified Professional Coder-Hospital (CPC-H): Current experience working in hospital-based outpatient departments or ambulatory surgery centers; associate degree recommended Certified Professional Coder-Payer (CPC-P): Current experience working for insurance companies or insurance billing services; associate degree recommended Speciality Certifications: Various medical coding certifications related to specific medical specialities; associate degree recommended Certified Coding Associate (CCA): An entry-level exam; six months of medical coding experience or completions of a medical coding training program Certified Coding Specialist (CCS): Three or more years of current experience in a hospital (inpatient) setting and demonstrated knowledge of anatomy, physiology, pathophysiology, and pharmacology Certified Coding Specialist Physician-Based (CCS-P): Three or more years of current experience in physician office settings and demonstrated knowledge of anatomy, physiology, pathophysiology, and pharmacology

14 12 A GUIDE TO Health Insurance Billing Beginning your career path as an insurance billing specialist can provide opportunities for advancement. Experience, education, and certification can lead to positions such as claims or billing department supervisor, medical office manager, collections manager, and medical practice manager. Insurance billing specialists with extensive insurance claims processing experience can establish a successful medical billing service. Table 1 6 provides information about these positions. Table 1 6 Career Positions Billing Department Supervisor Two or more years of current experience in all areas of health insurance billing Medical billing certification highly recommended Supervises insurance billing specialist Communicates with physicians, patients, and insurance companies to resolve insurance processing problems Collection Manager Two or more years of current experience in all areas of health insurance billing, including resolving problems related to collecting payment for services Medical billing certification highly recommended Communicates with patients, insurance companies, and collection agencies to secure payment for overdue or past due accounts Medical Office Manager Two years of current experience in a medical office Medical office manager certification highly recommended Associate s degree in office management or business administration recommended Establishes procedures for overall office functions Performs duties associated with staffing the office Communicates with physicians, office supervisors and staff, patients, and sales representatives Medical Practice Manager Associate s degree in accounting, business, or management required Bachelor s degree highly recommended Three or more years of accounting or business management experience in health care Communicates with physicians, hospital administrators, vendors, regulatory agencies, and other external agencies in matters related to the business and financial functions of the medical practice Responsible for all financial and business functions of the medical practice Establishes and implements policies that comply with state and federal laws and regulatory agency requirements Owner, Medical Billing Service Five or more years current experience in all areas of health insurance billing Two years of supervisory or management experience continued on the next page

15 The Insurance Billing Specialist 13 continued from the previous page Associate s degree in business, management, accounting, or health care administration Communicates with physicians, medical office managers, medical practice managers, insurance companies, and sales representatives Establishes medical billing (insurance claims submission) contracts with health care providers Establishes and implements policies and procedures that comply with state and federal laws and regulatory agency requirements REINFORCEMENT EXERCISES List three courses that are essential to an insurance billing specialist education program. 2. Spell out each abbreviation and then name the professional association that offers each credential. CMBS CMBS-H CMRS 3. Briefly describe the differences between the three medical coding certification exams offered by AHIMA. 4. Spell out and briefly describe CPC and CPC-H. Name the professional association that offers these credentials.

16 REVIEW 14 A GUIDE TO Health Insurance Billing ABBREVIATIONS Abbreviations are a fact of life in the health care industry. Table 1 7 lists the abbreviations presented in this chapter. Table 1 7 Abbreviations and Meanings Abbreviation AAPC AHIMA AMBA CAP CCA CCS CCS-P CE CHRS CMBS CMBS-CA CMBS-H CMRS CPC CPC-H CPC-P CPT ICD MAB NEBA Meaning American Academy of Professional Coders American Health Information Management Association American Medical Billing Association claims assistant professional certified coding assistant certified coding specialist certified coding specialist physician-based continuing education certified healthcare reimbursement specialist certified medical billing specialist certified medical billing specialist chiropractic certified medical billing specialist hospital certified medical reimbursement specialist certified professional coder certified professional coder hospital certified professional coder payer Current Procedural Terminology International Classification of Diseases Medical Association of Billers National Electronic Billers Alliance SUMMARY An insurance billing specialist is a key player in the financial operation of health care agencies. This individual processes health insurance claims in accordance with legal, professional, and insurance company guidelines and regulations. By observing an individual s behavior and by using personality inventory tests, one can identify personal qualifications. Technical qualifications are measurable skills that one can learn through education and experience. Employment and career opportunities for insurance billing specialists are readily available.

17 The Insurance Billing Specialist 15 REVIEW REVIEW EXERCISES Short Answer 1. Describe the different types of jobs that represent clinical and nonclinical career choices. 2. Briefly define insurance billing specialist. 3. List the office staff who work closely with the insurance billing specialist. Definition of Terms Fill in the blank beneath each definition with the appropriate term from the following list: certification, certified coding specialist, certified professional coder, claims assistance professional, insurance billing specialist, insurance collection specialist, insurance counselor, medical coding, medical terminology, patient account representative, personal qualifications, technical qualifications. 1. Credential offered by the American Health Information Management Association. 2. Individual who processes health insurance claims in accordance with legal and professional guidelines and regulations. 3. Behaviors that identify the character or personality of an individual. 4. Documenting medical information as numeric codes. 5. An individual who helps clients complete health insurance paperwork.

18 REVIEW 16 A GUIDE TO Health Insurance Billing 6. Language of the health care industry. 7. Measurable abilities and skills. 8. Helps resolve billing and payment problems between the medical office and the insurance company. 9. Establishes payment options before services are provided. 10. Successful completion of a professionally recognized exam. 11. Credential offered by the American Academy of Professional Coders. Matching Match each term in Column A with the appropriate item in Column B. Column A Column B a. self-motivated 1. interested in cross-training b. reliable 2. works well with others c. ethical 3. adheres to attendance policies d. detail-oriented 4. initiates work assignments e. data entry 5. maintains confidentiality f. cooperative 6. updates financial records g. communication skills 7. verifies diagnosis codes h. adaptable 8. uses correct grammar and spelling COMPREHENSION EXERCISES 1. Why does the insurance billing specialist need a working knowledge of medical terminology?

19 The Insurance Billing Specialist 17 REVIEW 2. Select the three personal qualifications that you believe are most important. Write a brief report explaining why you chose each of them. CRITICAL THINKING EXERCISES 1. Review the personal and technical qualifications listed in Tables 1 1 and 1 2. Compare the qualifications with the information in the Insurance Billing Specialist Job Description (Figure 1 2). Are the qualifications addressed in the job description? Match the qualification(s) with the corresponding statement(s). 2. Access the Medical Association of Billers website to review the sample certification exam questions. WEBSITES American Academy of Professional Coders (AAPC): American Health Information Management Association (AHIMA): American Medical Billing Association (AMBA): Medical Association of Billers (MAB): National Electronic Billiers Alliance (NEBA):