1 Role of an Insurance Billing Specialist

KEY TERMS

Your instructor may wish to select some specific words pertinent to this chapter for a test.

For definitions of the terms, further study, and/or reference, the words, phrases, and

abbreviations may be found in the glossary at the end of the Textbook. Key terms for this

chapter follow.

Linda M. Smith

American Medical Association

cash flow

claims assistance professional

claims examiner

cycle

electronic mail

errors and omissions insurance

ethics

etiquette

facility billing

independent contractor

insurance billing specialist

list service

medical billing representative

professional billing

reimbursement specialist

respondeat superior

revenue

self-pay patient

senior billing representative

See how many abbreviations and acronyms you can translate and then use this as a handy

reference list. Definitions for the key abbreviations are located near the back of the

Textbook in the glossary.

AAMA ______________________________________

_____________________________________________

_____________________________________________

AMA _______________________________________

ASHD _______________________________________

CAP ________________________________________

e-mail _______________________________________

listserv ______________________________________

MSO ________________________________________

NPP ________________________________________

PERFORMANCE OBJECTIVES

The student will be able to:

n Define and spell the key terms and key abbreviations for

this chapter, given the information from the Textbook

glossary, within a reasonable time period and with

enough accuracy to obtain a satisfactory evaluation.

n Answer the fill-in-the-blank, multiple choice, and true/

false review questions after reading the chapter, with

enough accuracy to obtain a satisfactory evaluation.

n Use critical thinking to write one or two grammatically

correct paragraphs with sufficient information to

obtain a satisfactory evaluation.

n Visit websites and site-search information via the Evolve

with sufficient information to obtain a satisfactory eval-

uation.

Chapter 1 Role of an Insurance Billing Specialist Copyright © 2020 Elsevier, Inc. All Rights Reserved.

STUDY OUTLINE

Background of Insurance Claims, Coding, and Billing

Role of the Insurance Billing Specialist

Job Responsibilities

Educational and Training Requirements

Career Advantages

Self-Employment or Independent Contracting

Flexible Hours

Disabled Workers

Qualifications and Attributes

Skills

Personal Image

Behavior

Medical Etiquette

Professional Ethics

Scope of Practice and Liability

Employer Liability

Employee Liability

Independent Contractor Liability

Claims Assistant Professional Liability

Future Challenges

3
Copyright © 2020 Elsevier, Inc. All Rights Reserved. Chapter 1 Role of an Insurance Billing Specialist

ASSIGNMENT 1.1 REVIEW QUESTIONS

Part I Fill in the Blank

Review the objectives, key terms, and chapter information before completing the following

review questions.

1. Name some of the settings where facility billing is used.

a.
__________________________________________________________________________________
_________

b.
__________________________________________________________________________________
_________

c.
__________________________________________________________________________________
_________

d.
__________________________________________________________________________________
_________

e.
__________________________________________________________________________________
_________

2. Name some of the various types of providers who use professional billing.

a.
__________________________________________________________________________________
_________

b.
__________________________________________________________________________________
_________

c.
__________________________________________________________________________________
_________

d.
__________________________________________________________________________________
_________

e.
__________________________________________________________________________________
_________

3. Name examples of non-physician practitioners (NPPs).

b.
__________________________________________________________________________________
_________

c.
__________________________________________________________________________________
_________

d.
__________________________________________________________________________________
_________

e.
__________________________________________________________________________________
_________

f._________________________________________________________________________________
___________

g.
__________________________________________________________________________________
_________

h.
__________________________________________________________________________________
_________

4. Name several job titles associated with medical billing personnel in both small and

large health care organizations.

a.
__________________________________________________________________________________
_________

b.
__________________________________________________________________________________
_________

c.
__________________________________________________________________________________
_________

Chapter 1 Role of an Insurance Billing Specialist Copyright © 2020 Elsevier, Inc. All Rights Reserved.

5. List some of the responsibilities and duties an insurance billing specialist might
perform generally, as well as when acting as a collection manager. Refer to the section

on “Job Responsibilities” in Fig. 1.1 of the text.

a.
__________________________________________________________________________________
________

b.
__________________________________________________________________________________
________

c.
__________________________________________________________________________________
________

d.
__________________________________________________________________________________
________

e.
__________________________________________________________________________________
________

f.
__________________________________________________________________________________
________

g.
__________________________________________________________________________________
________

6. List the duties of a claims-assistance professional.

a.
__________________________________________________________________________________
________

b.
__________________________________________________________________________________
________

c.
__________________________________________________________________________________
________

7. Insurance claims must be promptly submitted within _____________ business days

to ensure continuous cash flow.

8. Define cash flow.

__________________________________________________________________________________
__________
9. An individual who takes a patient to a private area before their visit with the provider

to discuss the practice’s financial policies and review the patient’s insurance coverage.

__________________________________________________________________________________
__________

10. Reasons for a medical practice’s large accounts receivable are:

a.
__________________________________________________________________________________
________

b.
__________________________________________________________________________________
________

c.
__________________________________________________________________________________
________

d.
__________________________________________________________________________________
________

11. Skills required for an insurance billing specialist are:

a.
__________________________________________________________________________________
________

b.
__________________________________________________________________________________
________

c.
__________________________________________________________________________________
________

d.
__________________________________________________________________________________
________

e.
__________________________________________________________________________________
________

Copyright © 2020 Elsevier, Inc. All Rights Reserved. Chapter 1 Role of an Insurance Billing Specialist
f.
__________________________________________________________________________________
________

g.
__________________________________________________________________________________
________

h.
__________________________________________________________________________________
________

i.
__________________________________________________________________________________
________

j.
__________________________________________________________________________________
________

12. Standards of conduct by which an insurance billing specialist determines the propriety

of his or her behavior in a relationship are known as ________________.

13. Complete these statements with either the word illegal or unethical.

a. To make critical remarks about another health care organization or physician is

b. To report incorrect information to a Medicare fiscal intermediary is

14. To treat a patient with a lack of courtesy is ________. When a physician is legally

responsible for an employee’s conduct during employment, it is known as ________.

15. A claims assistance professional neglects to submit an insurance claim to a Medicare

supplemental insurance carrier within the proper time limit. What type of insurance is

needed for protection against this loss for the client?

__________________________________________________________________________________
__________

Part II Multiple Choice

Choose the best answer.

16. Two billing components are facility billing and pro-

fessional billing. Professional billing is done for:

a. hospitals.
b. skilled nursing facilities.

c. ambulatory surgical centers.

d. physicians.

17. Physician extenders are health care personnel trained

to provide medical care under the direct or indirect

supervision of a physician, are also referred to as:

a. independent contractors.

b. claims assistance professionals (CAPs).

c. non-physician practitioners (NPPs).

d. insurance billing specialists.

18. The individual responsible for documenting the pa-

tient’s clinical notes and assigning a diagnosis code

and procedure code for medical services rendered is

a/an:

a. physician.

b. insurance biller.

c. office manager.

d. financial accounting clerk.

19. Insurance payers that require the provider to submit

insurance claims for the patient are:

a. federal and state programs.

b. private insurance plans.

c. managed care programs.

d. health care insurance plans.

20. Facility billing is charging for services done by:

a. hospitals.

b. physicians.

c. ambulatory surgical centers.

Chapter 1 Role of an Insurance Billing Specialist Copyright © 2020 Elsevier, Inc. All Rights Reserved.

Part III True/False

Write “T” or “F” in the blank to indicate whether you think the statement is true or false.

_______ 21. Insurance billing specialists have a well-defined scope of practice.

_______ 22. If you knowingly submit a false claim or allow such a claim to be submitted, you can be
liable for a civil

violation.

_______ 23. It is the coder’s responsibility to inform administration or his or her immediate
supervisor if unethical or

illegal coding practices are occurring.

_______ 24. A claims assistant professional (CAP) can interpret insurance policies for patients.

_______ 25. Independent contractors are covered under the health care organization’s professional
liability insurance

whom they provide services to.