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CMIS 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

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