MR 208 - Health Care Reimbursement

• explain medicolegal issues and the professional and career responsibilities of a medical insurance billing specialist;
• distinguish between basic insurance programs and contracts, including private insurance, managed care, Medicaid, Medicare, TRICARE, CHAMPVA, workers’ compensation, and other disability programs;
• state the fundamentals of health insurance coverage and describe various types of health insurance programs;
• demonstrate the use of source documents that relate to processing insurance claims;
• describe the insurance billing specialist’s role in the collection process and name payment and credit options available to patients;
• state ways to track reimbursement, interpret an explanation of benefits (remittance advice), and demonstrate completion of an authorization form, claim tracer, and an appeal;
• demonstrate use of diagnoses coding utilizing the International Classification of Diseases,9th Revision, (ICD-9-CM) reference book;
• demonstrate use of procedural coding utilizing the Current Procedural Terminology (CPT) reference book;
• demonstrate completion of the HCFA-1500 claim form for private insurance, managed care, Medicaid, Medicare, TRICARE, CHAMPVA, and worker’s compensation carriers;
• evaluate the key reimbursement systems in healthcare such as Diagnoses Related Groups, (DRG’s), Relative Value Studies (RVS), Resource Based Relative Value Scale (RBRVS) and the Ambulatory Payment Classification System (APC);
• differentiate the relationship between various coding and classification systems utilized in the health care reimbursement process;
• research and apply appropriate Federal, State, & Private Payer guidelines/regulations. (CMS, HCFA, Third Party Payers);
• process claims for reimbursement to include:
  • manual and electronic preparation of claims;
  • tracing claims;
  • sequence of filing (eg. Primary vs. secondary);
  • reconciling payments/rejections; and
  • inquiry and appeal process.
• apply managed care policies and procedures for referrals, recertification and fee schedule payments; and
• list ways of analyzing and controlling the payment collection process which includes: collecting/updating demographic data, billing cycles and itemization, aging/controlling accounts receivable and the collection process.