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Certified Medical Insurance Specialist (CMIS)^®

Coding expertise is the foundation. But if you want to get paid, then you’ll need to know the rules. This certification program explores the current landscape of third party reimbursement. Detailed lecture and course materials will teach participants how to effectively expedite claims, secure timely, correct reimbursement, and protect the financial interest of the practice.

How good is your billing team?

There’s room for improvement in every practice. Seasoned billing professionals will walk away from this program with an improved outlook, confidence, and ability to handle tough claims.

Today more than ever, your team must be trained to focus on getting every dollar rightfully owed to the practice. This program will teachyou how to master the entire process, better train those around you, and enhance your professional skills and value.

The Certified Medical Insurance Specialist program has passed a thorough review process, ensuring that materials are current and accurate, and testing standards are strictly enforced. Board and faculty members have real-world experience in all ­aspects of running a successful medical practice. Representatives include seasoned physicians, educators, accountants, compliance officers and senior executives in medical practice management.

Course Outline

The Insurance Billing Specialist Role and Responsibilities

• Medical Insurance Specialist job description
• Differentiate between medical ethics and medical etiquette
• Learn essential ways to keep insurance and medical knowledge current
• Identify the background and importance of accurate insurance claims submission, coding, and billing

Compliance

• Major categories of security safeguards under HIPAA and the civil and criminal penalties of non-compliance with HIPAA regulations
• The Privacy Rule as it pertains to protected health information
• Definition and explanation of protected health information (PHI)
• Definition of fraud and abuse and potential fines and penalties related to billing insurance claims

Basics of Health Insurance

• The difference between an implied and an expressed physician-patient contract
• Actions to prevent problems when given signature authorization for insurance claims
• Fundamental elements of insurance
• Physician Fee Schedule - RVUs and RBRVS

Medical Documentation

• Identify principles and steps of the documentation
• Definitions for common medical, diagnostic and legal terms
• Reasons why an insurance company may decide to perform an external audit

Diagnostic Coding

• The purpose and importance of coding diagnoses to the highest level of specificity
• Use diagnostic code books properly and obtain codes accurately
• Perform diagnostic coding accurately after completing the problems on worksheets

Procedural Coding

• The importance and usage of modifiers in procedure coding
• Code problems from worksheet using the CPT manual
• The difference between CPT and HCPCS, Category II and Category III codes

The Paper Claim: CMS-1500

• Minimize the number of insurance forms returned because of improper completion
• Detailed look at the CMS-1500 and what each section contains
• Expedite the handling and processing of the CMS-1500 insurance claim form
• Explain the difference between clean, rejected, incomplete, and invalid claims

Electronic Data Interchange Transactions and Security

• Transactions and code sets for insurance claims transmission
• The difference between carrier-direct and clearinghouse electronically transmitted insurance claims
• Using patient encounter forms in electronic claims submission
• How to conquer potential computer transmission problems

Receiving Payments and Insurance Problem Solving

• Objectives of state insurance commissioners/state medical societies
• Communicating problems with insurance commissioners/state medical societies
• Denials and what they mean; how to appeal for maximum reimbursement
• Levels of review and redetermination in the Medicare program
• Sample letters of appeals for claims

Office and Insurance Collection Strategies

• More effective collections
• Patient credit options that yield big results
• Effective uses of a billing service, collection agency, and credit bureau in the collection process
• When to direct delinquent collections to small claims court
• Guidance on state prompt pay laws

Managed Care Plans

• Understanding types of managed care plans
• Explain and understand the difference in various managed care plans
• Types of authorizations for medical services, tests, and procedures

Medicare

• Differentiate between an HMO Risk Plan and an HMO Cost plan
• Utilizing the lifetime beneficiary claim authorization and information release document
• How to submit claims for Medicare beneficiaries with supplemental insurance

Medicaid and Other State Programs

• Medicaid managed care system guidelines, terminology, abbreviations, eligibility classifications, benefits and non-benefits
• Filing Medicaid claims for patients who have other coverage
• Minimize Medicaid rejections due to improper form completion

Worker’s Compensation

• Workers’ compensation insurance vs. employer’s liability insurance
• Types of compensation benefits for non-disability, temporary disability, and permanent disability claims
• Terminology and abbreviations pertinent to worker’s compensation cases
• Follow-up actions for delinquent worker’s comp claims
• Signs of fraud and abuse involving employees, employers, insurers, medical providers, and lawyers, and when to report

Disability Income Insurance and Disability Benefit Programs

• Explanation and eligibility requirements for disability benefit programs and voluntary disability insurance plans
• Terminology and abbreviations for disability insurance and benefit programs
• How to determine whether disability is considered temporary or permanent
• State eligibility requirements, benefits, and limitations of SSDI and SSI

Certified Medical Insurance Specialist (CMIS)® is for those individuals seeking to master the complete reimbursement process, from information gathering, through coding, to challenging and prevailing in claim denial situations.

Course Prerequisite

Working knowledge of medical insurance processing in an outpatient setting is required. Participants with less than one year of experience should enroll in supplemental coding and medical records training prior to enrolling in this program.

For added support, participants may elect to purchase a pre-recorded lecture on a flash drive for an additional $199, available with live class enrollment.

Required Class Materials

Students must bring current editions of CPT, ICD-9-CM, HCPCS manuals and a medical dictionary to each class.

Payment Plan Available

PMI is helping medical office professionals fit career training into their budget. Plan ahead and spread your payments out over three installments. Print PMI’s Easy Pay Consent Form: www.pmiMD.com/paymentplan.asp or call 800-259-5562 for more details.

Can’t Attend the Live Class?

2 Alternate Ways to Earn Your CMIS Now

Live Webinar

PMI’s newest, most convenient certification training format. Get access to live training without the expensive travel and missed work days sacrificed to attend a live class. Participate in the lecture over a toll-free phone line and view the PowerPoint presentation online while you follow along with the class manual mailed to you prior to the start of the program. Free support through PMI’s online Q&A forum and toll-free faculty help line. Certification exams are proctored live in a community near you. Click the “Live Webinar” heading, above, for more information

Certification by Exam

For those with proven coding skills and experience, an “Exam Only” option is available for $299 testing fee. The exam is proctored live in hundreds of locations across the country. Exam fee includes the basic exam preparation handbook. Click the “Certification by Exam” heading, above, for more information.