Chapter 1

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Health

Insurance Specialist Career

Chapter 1


Career Opportunities

• Coding is the process of assigning ICD-9-CM and CPT/HCPCS codes to diagnoses, procedures, and services.


Career Opportunities• Health insurance and

reimbursement specialists review claims received by insurance carriers to determine that “medical necessity” is proven forprocedures and services submitted.

• A claims examiner employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable and for medical necessity


Opportunities for Insuranceand Reimbursement Specialists

• State, local, and Federal government agencies

• Legal offices

• Private insurance billing offices

• Medical societies


Overview of Role of Insurance Specialist

• Responsible for filing health insurance claims

• Handle timely reimbursement for appropriate documentation submitted


How Does an Insurance Specialist Stay Up-to-Date?

A. Receive carrier newsletters

B. Understand your contracts

C. Remain Current


Education and Training

• Understanding HCPCS coding systems

• ICD-9-CM coding systems

• Anatomy and physiology

• Communication skills

• Human relations

• Computer applications


Training Requirements

• Anatomy and physiology

• Coding

• Communication

• Critical thinking

• Data entry

• Student internship


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

– Need to explain complex concepts and regulations to effectively communicate with their providers regarding documentation requirements to reduce errors


Characteristics of Insurance Specialists

• Ability to work independently

• Strong sense of ethics

• Ability to pay attention to detail

• Ability to think critically


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.


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


Job Description

• 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


Job Description

• Research and appeal all underpaid or denied claims

• Trace all claims not paid within 30–45 days and rebill if necessary

• Notify staff and providers of any changes in coding or documentation guidelines effecting denials


Job Description

• Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements

• Maintain internal audit system

• Explain benefits, policy requirements, filing requirements, and payments to patients

• Maintain confidentiality of patient information


Scope of Practice

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


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

• 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


Responsibilities

• Knowledge of medical management computer software to process health insurance claims

• Knowledge of insurance coverage, repayment issues, and health care laws and regulations

• Communicate with insurance companies and patients regarding coverage and reimbursement issues


Professionalism

• Conduct or qualities that characterize a professional person

– Attitude and self-esteem

– Communication

– Conflict management

– Customer service

– Diversity awareness

– Leadership

– Managing change

– Productivity

– Professional ethics

– Team building


Telephone Skills

• All health care team members must effectively handle or transfer telephone calls.

– Requires sensitivity to patient concerns about health care problems, and the health care professional must communicate a caring environment that leads to patient satisfaction


Professional Associations

• American Academy of Professional Coders (AAPC)

• American Association of Medical Assistants (AAMA)

• American Health Information Management Association (AHIMA)

• American Medical Billing Association (AMBA)• Medical Association of Billers (MAB)• National Electronic Billers Alliance (NEBA)

Chapter 1

Education

job description

critical thinking

career opportunities

communication

payments

coding

communicate

services