Certified Medical Insurance Specialist

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

Compliance

• 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
• Medical Documentation
• 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

• 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

Procedural Coding

• 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

Medicare

• 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

• 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

Pam Joslin, MM, CMC, CMIS, CMOM, CMCO, CMCA-E/M, CEMA

Pam has more than 20 years of medical practice management, coding, reimbursement and compliance experience. She has managed in medical practices ranging from single to multi-specialty groups, including ASC.

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.

Current editions of CPT®, HCPCS, ICD-10-CM, and a medical dictionary are required for use during this course.