MEDI 101- MEDICAL

INSURANCE AND CODING

HEALTH INSURANCE
SPECIALIST CAREER
 Topic Outline
A. Health Insurance Overview
B. Health Insurance Career Opportunities
C. Education and Training
D. Job Responsibilities

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Objectives
1. Define key terms
2. Discuss introductory health insurance concepts
3. Identify career opportunities available in health insurance
4. List the education and training requirements of a health
insurance specialist
5. Describe the job responsibilities of a health insurance
specialist
6. Explain the role of workplace professionalism in career
success.

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Health Insurance Overview
Health Insurance Claim-is a document submitted to a third-party
payer or a government program requesting reimbursement for
healthcare services provided
Preauthorization- or Prior Approval – for treatment by specialist and
documentation of post-treatment reports.
If plan has Hold harmless clause- patient is not responsible for
paying what insurance plan denies.
Healthcare Provider- is a physician or other healthcare practitioner
Centers for Medicare and Medicaid Services (CMS)- Administrative
Agency within the federal department of health and Human Services

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Health Insurance Career Opportunities
A. Health Insurance Specialists (Reimbursement specialists)- review
health-related claims to determine the medical necessity for procedures or
services performed before payment (reimbursement) is made to the
provider.
B. Claim Examiner- Employed by a third-party payer review health-related
claims to determine whether the charges are reasonable and for medical
necessity
Medical necessity- justification the necessity to perform a procedure
C.Medical Assistant-is employed by a provider to perform administrative
and clinical task that keeps the office or clinic running smoothly.
Coding- is the process of assigning ICD and CPT/HCPCS codes to
diagnoses,procedures, and services.

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Other settings for insurance specialist
- Claims benefit advisors in health, malpractice, and liability insurance companies.
- local, and federal government agencies, legal offices, and verification specialists
in healthcare organizations.
-Educators in School
-Writers and editors of health insurance textbooks, newsletter, and other
publications.
-Self-employed consultants who provide assistance to medical practices with
billing practices and claims appeal procedures
-Consumer claims assistance professionals
-Practices with poorly trained health insurance staff who are unwilling or unable to
file a proper claims appeal.
-Private billing practices dedicated to claims filing for elderly or disabled patients.

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Education and Training
Academic Programs include:
General Education on:
1. Anatomy and Physiology
2. English composition
3. Oral Communications
4. Human Relations
5. Computer Application

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Continuation…
Health Insurance Specialist Education
1. Health Information Management
2. Medical Terminology
3. Pharmacology
4. Coding and Reimbursement
5. Insurance Processing

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Characteristics of a successful health insurance
specialist

1. Ability to work independently

2. A strong sense of ethics
3. Attention to details
4. Ability to think Critically

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Training Requirements for Health Insurance
Specialists
Coursework:
1. Anatomy and Physiology
2. Diagnosis and Procedures/Service Coding
3. Verbal and Written Communication
4. Critical Thinking
5. Data Entry – Online information sources provide access to
medical references, insurance company manuals, procedure
guidelines.

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Job Responsibilities
1. Review Patient record documentation to accurately code all
diagnoses, procedures, and services using ICD/CPT/HCPCS
2. Research and apply knowledge of all insurance rules and
regulations for major insurance programs in the local or
regional area.
3. Accurately post charges, payments, and adjustments to
patient accounts and office accounts receivable records.
4. Prepare or review claims generated by the practice to ensure
that all required data are accurately reported and to ensure
prompt reimbursement for service provided.

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Continuation…
5. Review all insurance payments and remittance advice documents
to ensure proper processing and payment of each claim.
EOB- Explanation of Benefits- a report detailing the result of
processing claim
Remittance Advice- is a notice sent by the insurance company that
contains payment information about a claim.
6. Correct all data all errors and resubmit all unprocessed or
returned claims.
7. Research and prepare appeals for all underpaid, unjustly recorded,
or denied claims.
8. Explains insurance benefits, policy requirements, and filing rules
to patients.
9. Maintain confidentiality of patient information

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Scope of Practice and Employer Liability
Regardless of the employment setting health insurance specialists are
guided by a “SCOPE of PRACTICE”

Independent Contractor- a person who performs services for another

under and express or implied agreement and who is not subject to
other’s control.

Professional liability insurance / Errors and Omissions insurance-

provides protection from claims that contain errors and omissions
resulting from professional services provided to clients
*** “Respondeat Superior”

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 Types of Professional Insurance Purchased by
Employers
1. Bonding Insurance- Insurance agreement that guarantees
repayment for financial losses resulting from an employee’s
act or failure to act.
2. Business liability Insurance-Protects business assets and
covers the cost of lawsuits resulting from bodily injury.
Medical malpractice insurance
3. Property Insurance
4. Workers’ compensation insurance- mandated by the state law
that covers employees and their dependents against injury and
death occurring during the course of employment.

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 Professionalism
The conduct or qualities that characterize a professional person.

1. Attitude and Self-esteem

2. Communication
3. Conflict Management
4. Customer Service
5. Diversity Awareness
6. Leadership
7. Managing Change
8. Productivity
9. Professional Ethics
10. Team-building

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Telephone skill for Healthcare Setting
Avoid problems with telephone communication in your
healthcare setting by implementing the following protocols.
1. Establish a telephone availability policy that works for
patients and office staff.
2. Setup an appropriate number of dedicated telephone lines
(e.g. appointment scheduling, insurance and billing).
Publish the telephone numbers on the office’s web site and
in an office brochure.
3. Inform callers who ask to speak with the physician that the
physician is with a patient.

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Continuation…
4. Assign 15-minute time periods every 2-3 hours when creating
a schedule.
5. Physically separate front desk check-in/check-out and
receptionist/patient appointment scheduling offices.
6. Require office employees to learn professional telephone
skills.

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Telephone Conversation Rules:
1. When answering the telephone, state the name of the office and your name
(e.g., DMMMSU Center, Joseph Acosta Speaking)
2. Do not use slang (e.g. nope, yep, uh huh) or healthcare jargon
3. Use the caller’s name
4. Provide clear explanation
5. Be Pleasant, friendly, sincere and helpul.
6. Give the caller your undivided attention to show personal interest, and do not
interrupt.
7. Before placing the caller on hold or transferring a call, ask him or her for
permission to do so.
8. When the individual with whom the caller wants to talk is unavailable, ask if
you can take a message.
9. Use a preprinted message form (or commercial message pad) when taking a
message.

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Message Pad

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 Professional Credentials
-American Academy of Professional Coders (AAPC)
Certified Professional Coder (CPC)
-American Association of Medical Assistants (AAMA)
Certified Medical Assistant (CMA)
-American Health Information Management Association (AHIMA)
Certified Coding Assistant (CCA)
Certified Coding Specialist (CCS)
Certified Coding Specialist-Physician-Office
-American Medical Billing Association (AMBA)
Certified Medical Reimbursement Specialist (CMRS)
-Medical Association of Billers (MAB)
Certified Billing Specialist (CMBS)
-National Electronic Biller Alliance (NEBA)
Certified Healthcare Reimbursement Specialist
Certified HIPAA Information Specialist.

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END
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