Learn the current guidelines and responsibilities to manage third-party provider reimbursement. The instructor will explain types of managed care plans and guidelines for working with third-party payers. Review documentation, diagnostic and procedural coding rules, and compliance. Participants will learn collection strategies, tips, and receive problem-solving guidance.
CMIS candidates with less than a year of coding experience should complete the PMI Basics: Introduction to Medical Coding Self-Paced course prior to enrollment.
Required Self-Supplied Materials
The following coding resources are required to study for this course and for use during the exam: current editions of CPT®, HCPCS, ICD-10-CM, and a medical dictionary. The ICD-10-CM code set for 2019 will be effective October 1, 2018, through September 30, 2019. CPT and HCPCS code sets are effective for the calendar year period beginning January 1 and ending December 31.
Candidates that schedule their exam in the next calendar year should bring the updated coding books for the exam. Practice Management Institute (PMI) updates the course and exam annually using the current American Medical Association (AMA) published versions of the three coding manuals.* Use of these resources will minimize potential discrepancies in coding information provided. The AMA publishes the only CPT® codebook with the official CPT guidelines. PMI does not sell medical coding books, but they are widely available for purchase or lease through a variety of nationwide publishers and retailers.
*Recommendation and use of AMA coding books does not indicate the endorsement of a particular brand by Practice Management Institute.
Learn the current guidelines and responsibilities to manage third-party provider reimbursement. The instructor will explain the types of managed care plans and guidelines for working with third-party payers. Review documentation, diagnostic and procedural coding rules, and compliance. Participants will learn collection strategies, tips, and receive problem-solving guidance.
The CMIS course will guide participants through the first claims pass and includes new reject/denial practice exercises from real cases to help solidify knowledge. Staff will return to the office with a keen understanding of their role and responsibility for protecting practice revenue.
Roles and Responsibilities
- Differentiate between medical ethics and medical etiquette
- Learn essential ways to keep insurance and medical knowledge current
- Demonstrate the importance of accurate coding, billing and claims submission
- Major categories of security safeguards under HIPAA and civil/criminal non-compliance penalties
- The Privacy Rule and the definition and explanation of protected health information (PHI)
- Definition of fraud and abuse and potential fines/penalties related to fraudulent claims
- Health information technology expansion: ARRA, HITECH and the creation of incentive payments
to eligible providers
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
- Physician Fee Schedule - RVUs and RBRVS
- MACRA and repeal of SGR formula
- Identify the 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
ICD-10-CM Diagnostic Coding
- The purpose and importance of coding diagnoses to the highest level of specificity
- Features and use of ICD-10-CM codebook for accurate code selection
- In-class diagnostic coding exercises
- Determine medical necessity by using LCDs and NCDs
- The importance and usage of modifiers in procedure coding
- Code problems from the worksheet using the CPT® manual
- The difference between CPT, HCPCS, and Category II codes
- Use of the NCCI edits to prevent denials
The Paper Claim: CMS-1500
- Minimize the number of insurance forms returned because of improper completion
- Review CMS-1500 by section
- 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
- Transaction and code set standards to share data between clinicians and third-party payers
- The difference between carrier-direct and clearinghouse electronically transmitted claims
- How to conquer potential computer transmission problems
- The use of EDI standards improve the accuracy of information exchanged between healthcare organizations
- Streamline business processes by using EDI standards as an eligibility and claims processing gateway
Receiving Payments and Insurance Problem-Solving
- Objectives of state insurance commissioners/state medical societies
- Communicate problems with insurance commissioners/state medical societies
- Working with denials and rejects; how to appeal for correct reimbursement
- Levels of review and redetermination in the Medicare program
- Sample letters of appeals for claims
Office and Insurance Collection Strategies
- Guidance on state prompt pay laws and the use of financial reports for more effective collections
- Patient credit options and the best practices for self-pay accounts
- Working with a billing service, collection agency, and credit bureau in the collection process
- The effects of the Affordable Care Act provisions on collections
Managed Care Plans
- Explanation of the types of managed care plans
- Types of authorizations for medical services, tests, and procedures
- Patient access to care via Accountable Care Organizations and Patient-Centered Medical Homes
- Special issues when patients are insured through the Health Insurance Exchanges
- Utilize the lifetime beneficiary claim authorization and information release document
- How to submit claims for Medicare beneficiaries with supplemental insurance
- Proper execution of an Advance Beneficiary Notice (ABN)
- Medicare as a secondary payer rules
Medicaid and other State Programs
- Medicaid managed care system guidelines, terminology, abbreviations, eligibility classifications, benefits and non-benefits
- Medicaid claims filing for patients who have other coverage
- Minimize Medicaid rejections due to improper form completion
- Workers’ compensation insurance vs. employer’s liability insurance
- Types of compensation benefits for non-disability, temporary, and permanent disability claims
- Follow-up actions for delinquent worker’s comp claims
Disability Income Insurance and Disability Benefit Programs
- Explanation and eligibility requirements for disability benefit programs and insurance plans
- Terminology and abbreviations for disability insurance and benefit programs
- How to determine whether the disability is considered temporary or permanent
- State eligibility requirements, benefits, and limitations of SSDI and SSI
Attend instructor-led classroom sessions, hosted in select hospitals, healthcare organizations, medical societies and colleges across the U.S.
Live Certified Medical Insurance Specialist classroom format includes a full course manual, and timed four-hour proctored certification exam. A score of 70% or better is required to earn the CMIS certification. If a passing grade is not achieved on the first attempt, candidates may re-test for an additional fee.
Participate in the Certified Medical Insurance Specialist course remotely with access to a series of ten live 90-minute instructor-led webinar sessions (limited availability).
This format also includes a full course manual and timed, four-hour proctored certification exam scheduled by PMI’s Exam Coordinator in a testing center near the candidate’s location. A score of 70% or better is required to earn the CMIS certification. If a passing grade is not achieved on the first attempt, candidates may re-test for an additional fee.
Start the Certified Medical Insurance Specialist online training program anytime with access to ten pre-recorded 90-minute instructor-led sessions.
The Certified Medical Insurance Specialist on-demand format includes a full course manual and timed, four-hour proctored certification exam scheduled by PMI’s Exam Coordinator in a testing center near the candidate’s location. A score of 70% or better is required to earn the CMIS certification. If a passing grade is not achieved on the first attempt, candidates may re-test for an additional fee.
Experienced professionals may choose to challenge the Certified Medical Insurance Specialist certification exam for a $299 fee.
Exam challenge fee includes a basic exam guide and a timed, four-hour proctored certification exam scheduled by PMI’s Exam Coordinator in a testing center near the candidate’s location. A score of 70% or better is required to earn the CMIS certification. If a passing grade is not achieved on the first attempt, candidates may re-test for an additional fee.
Are your claim follow-up procedures effective?
Are ABNs and authorizations being correctly processed?
Has your ratio of outstanding claims decreased in the last 2 years?
Are your aging reports under control?
Every practice has room for improvement. Today more than ever, your team needs proper training to focus on getting every dollar rightfully owed to the practice. This program will teach you how to master the entire process, better train those around you and enhance your professional skills and value