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

Linda is a medical practice management consultant who helps providers and their staff improve business processes such as reimbursement, documentation guidelines, procedural and diagnostic coding, financial management, human resources, medical office management, compliance, OSHA, and HIPAA. She has also served as an Independent Review Organization (IRO) for the Office of the Inspector General and consulted for the Texas Medical and Dental Boards.

Linda has more than 30 years of experience and has managed cardiology, cardiothoracic, vascular surgery, physical therapy, orthopedics, pediatric orthopedics, gynecology and reproductive endocrinology, and large multispecialty group practices. She has maintained broad responsibilities in business and clinical operations, financial management, governance and organizational dynamics, human resource management, marketing, customer service, compliance, information system management, mergers and acquisitions, and risk management.

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.