health insurance specialist medical coder biller career n.
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health insurance specialist medical coder biller career




career opportunities
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.
career opportunities1
Career Opportunities
  • 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.
career opportunities2
Career Opportunities
  • The claims review process requires
  • Verifications 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 more thorough review
career opportunities3
Career Opportunities
  • Codding 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)

The following will be implemented on October 1, 2013

  • International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
  • International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
career opportunities4
Career Opportunities
  • Healthcare Common Procedure Coding System
  • Current Procedural Terminology (CPT)
  • HCPCS level II codes (national codes)
opportunities available
Opportunities Available
  • Claims benefit advisors
  • Coding or insurance specialists
  • Educators in schools
  • Writers and editors
  • Self-employed consultants
  • Private billing practices
opportunities for insurance and reimbursement specialists
Opportunities for Insurance and Reimbursement Specialists
  • Advisors on claims submitted
  • Health insurance claims
  • Malpractice
  • Liability insurance carriers
opportunities for insurance and reimbursement specialists cont
Opportunities for Insurance and Reimbursement Specialists (cont.)
  • State, local, and federal government agencies
  • Legal offices
  • Private insurance billing offices
  • Medical societies
opportunities for insurance and reimbursement specialists cont1
Opportunities for Insurance and Reimbursement Specialists (cont.)
  • Medical practice consultants
  • Auditors
  • Compliance monitors
opportunities for insurance and reimbursement specialists cont2
Opportunities for Insurance and Reimbursement Specialists (cont.)
  • Instructors for community education programs specializing in training medical billers and coders
  • Textbook writers
  • Newsletter writers
  • Industry publications
overview of role of insurance specialist
Overview of Role of Insurance Specialist
  • Responsible for filing health insurance claims
  • Handles timely reimbursement for appropriate documentation submitted
contracting decisions
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
how does an insurance specialist stay up to date
How Does an InsuranceSpecialist 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.
how does an insurance specialist stay up to date cont
How Does an Insurance Specialist Stay Up-to-Date? (cont.)
  • Remain current
  • Regarding news releases from CMS
  • Regarding changes in industry
  • Regarding new technology
education and training
Education and Training
  • HCPCS coding systems
  • ICD-9-CM and ICD-10-CM and ICD-10-PCS coding systems
  • Anatomy and physiology
  • Communication skills
  • Human relations
  • Computer applications
skills needed
Skills Needed
  • Insurance specialist positions require
  • Background in word processing
  • Knowledge of
  • Computer applications
  • Anatomy and physiology
  • Medical terminology
  • Insurance claims processing
skills needed cont
Skills Needed (cont.)
  • Excellent keyboarding skills
  • Basic math skills
  • In this detail-oriented industry
  • Typographical errors can completely change the information provided.
characteristics of insurance specialists
Characteristics of Insurance Specialists
  • Ability to work independently
  • Strong sense of ethics
  • Ability to pay attention to detail
  • Ability to think critically
definition of ethics
Definition of Ethics
  • The American Heritage Concise Dictionary
  • “Principles of right or good conduct and the rules that govern the conduct of members of a profession”
why training is necessary in coding
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
communication skills needed
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
communication skills needed1
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.
training requirements
Training Requirements
  • Anatomy and physiology
  • Coding
  • Communication
  • Critical thinking
  • Data entry
  • Internet access
student internship
Student 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.
job description
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 cont
Job Description (cont.)
  • 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 cont1
Job Description (cont.)
  • Research and appeal all underpaid or denied claims.
  • Trace all claims not paid within 30 to 45 days and rebill if necessary.
  • Notify staff and providers of any changes in coding or documentation guidelines affecting denials.
job description cont2
Job Description (cont.)
  • Assist in updating practice registration and billing forms in accordance with changes to coding and billing requirements.
  • Maintain internal audit system.
job description cont3
Job Description (cont.)
  • Explain benefits, policy requirements, filing requirements, and payments to patients.
  • Maintain confidentiality of patient information.
scope of practice
Scope of Practice
  • Work with patients to make clear what their health insurance covers and their financial responsibility.
employer liability
Employer Liability
  • Self-employed - Independent contractors
  • Professional liability insurance
  • Respondeat superior – “Let the master answer”
  • Graduate of health insurance specialist (Medical Coder/Biller) certificate or degree program
  • Understanding of insurance billing/collection processes
  • Outstanding organizational skills and aptitude to manage multiple tasks in a timely manner
qualifications cont
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
  • Knowledge of medical management computer software to process health insurance claims
  • Knowledge of insurance coverage, repayment issues, and healthcare laws and regulations
responsibilities cont
Responsibilities (cont.)
  • Communication with insurance companies and patients regarding coverage and reimbursement issues
supervision requirements
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.
employer insurance
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.
professional insurance
Professional 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.
  • Conduct or qualities that characterize a professional person
  • Attitude and self-esteem
  • Communication
  • Conflict management
  • Customer service
  • Diversity awareness
professionalism cont
Professionalism (cont.)
  • Leadership
  • Managing change
  • Productivity
  • Professional ethics
  • Team building
telephone skills
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.
telephone skills cont
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.
telephone skills cont1
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.
telephone skills cont2
Telephone Skills (cont.)
  • Physically separate front desk check-in/check-out and receptionist/patient appointment scheduling offices.
  • Require office employees to learn professional telephone skills.
professional associations
Professional Associations
  • American Academy of Professional Coders (AAPC)
  • American Association of Medical Assistants (AAMA)
  • American Health Information Management Association (AHIMA)
professional associations cont
Professional Associations (cont.)
  • American Medical Billing Association (AMBA)
  • Medical Association of Billers (MAB)