Role of an Insurance Billing Specialist

1
Chapter 1

• Role of an Insurance Billing Specialist

2
Background

• Service Goal--Revenue cycle
• Health care industry one of most heavily
  regulated in US
• Billing components
• Hospital billing
• Professional billing
• Payment schedules
• Relative value units

3
Basic Setup of an Office

• Reception of the patient
• Rendering of medical services
• Documentation of the services
• Financial accounting
• All above affect payment for services

4
Office Procedures

• Scheduling appointments
• Registering patients
• Documenting
• Charging entries
• Filing
• Bookkeeping and accounting

5
Titles

• Insurance Billing Specialist
• Electronic Claims Processor
• Reimbursement Specialist
• MSO Management Service Organ.
• MSHPs Multiskilled health practitioners
• CAPs Claims assistance professionals

6
Job Responsibilities

• Generic job descriptionsFig 1-1 to 1-4
• Documentation
• Reviewing diagnostic and procedural coding
• Promptly filing insurance claims (cash flow)
• Insurance counselor
• Collection manager
• Low accounts receivables
• Table 1.1, pg. 14

7
Education and Training

• Medical terminology
• Insurance claim completion
• Procedural and diagnostic coding
• Anatomy and physiology
• Computer skills
• Ethics and medicolegal knowledge
• General office skills

8
Career Advantages

• Self-employment
• Flexible hours
• Disabled workers

9
Qualifications

• Attributes
• Critical thinking
• Logical and practical thinking
• Meticulous
• Good organizational skills
• Skills
• Solid foundation of medical terminology
• Expert use of CPT/IDC-9 code books

10
Qualifications Skills (continued)

• Precise reading skills
• Basic math
• Knowledge of medicolegal rules and regs
• Basic typing/keyboarding/computer skills
• Proficiency in accessing info through the
  Internet
• Knowledge of billing and collection techniques
• Expertise in legalities of collections
• Generate insurance claims with speed and accuracy

11
Qualifications

• Personal image
• Behavior

12
Medical Etiquette

• How medical professionals conduct themselves
• Consideration for others

13
Medical Ethics

• Standards of conduct accepted as a moral guide
  for behavior
• Its illegal to report incorrect info to
  government-funded programs
• Its unethical to report incorrect info to
  private insurance carriers
• Page 20

14
Illegal or Unethical Coding

• Using code numbers or modifiers to increase
  payment
• Coding for procedures that were not performed
• Unbundling services into separate codes
• Failure to code relevant condition
• Coding another condition as principal diagnosis

15
Professional Liability

• Physicians legal responsibility
• Employees legal responsibility
• Errors and omissions insurance

16
Future Challenges

• You are expected to profitably manage a medical
  practices financial affairs and patient
  accounts.
• Page 22.