Responsibilities of the Reimbursement Specialist include the following:
1. Observe legal and ethical guidelines for safeguarding the confidentiality of patient and proprietary information.
2. Understands billing requirements for Medicare, Medicaid, contracted and commercial payers
3. Follows up on denials in a timely manner and proactively communicates any denial issues related to billing requirements
4. Reviews EOB for proper reimbursement
5. Monitors contracts and single patient agreements to ensure appropriate reimbursement is received
6. Ensures timely filling requirements are met and claims are followed up on in a timely and appropriate manner to eliminate timely filing denials and non-payment of claims
7. Understands governmental and commercial compliance regulations related to healthcare billing and accounts receivable management and where to locate the regulations
8. Reviews and researches insurance correspondence and makes necessary corrections to ensure claims payment
9. Follows up on unresolved account balances
10. Understanding of both UB04 claim for and CMS 1500 claim form
11. Provides insurance carriers with requests as necessary and timely
Sunday, September 20, 2009
I am keeping up with the current debate over health care and insurance reform.
The current efforts to overhaul our health care and medical system by Congress will have a direct impact on medical insurance billing specialists.
Monday, September 14, 2009
My reasons why you should interview me.
Dear Employer,
Because of current market conditions and high unemployment, I am sure you have many
candidates for few medical billing and coding positions. Please allow me to give you a few reasons why you might want to call me ahead of other candidates who may have years of experience in medical billing and coding.
You will note that my background includes experience as an accountant and tax preparer.
I am able to work well and quickly with numbers and formulas and
knowledge of the laws, rules and regulations withing which I must operate.
My recent completion of a comprehensive billing and coding
course prepared me to work well for any health provider.
I am hoping that your office would prefer a candidate with
enough background, experience and specific training to be open
and flexible to how your facility wants it done.
Recent changes with more expected in the health care industry
which create frustration for more experienced medical billing
and coders, their employers and the consumers.
My character, personality and ability to apply my knowledge and experience make me
perfect for interacting with all involved in the billing process. I would greatly appreciate a few minutes of your time to discuss my options and glean any suggestions you can offer. I will phone you in a few days to see if we can schedule a brief meeting.
Thank you.
Regards,
Claudia Tanzer
Enclosure: resume
Because of current market conditions and high unemployment, I am sure you have many
candidates for few medical billing and coding positions. Please allow me to give you a few reasons why you might want to call me ahead of other candidates who may have years of experience in medical billing and coding.
You will note that my background includes experience as an accountant and tax preparer.
I am able to work well and quickly with numbers and formulas and
knowledge of the laws, rules and regulations withing which I must operate.
My recent completion of a comprehensive billing and coding
course prepared me to work well for any health provider.
I am hoping that your office would prefer a candidate with
enough background, experience and specific training to be open
and flexible to how your facility wants it done.
Recent changes with more expected in the health care industry
which create frustration for more experienced medical billing
and coders, their employers and the consumers.
My character, personality and ability to apply my knowledge and experience make me
perfect for interacting with all involved in the billing process. I would greatly appreciate a few minutes of your time to discuss my options and glean any suggestions you can offer. I will phone you in a few days to see if we can schedule a brief meeting.
Thank you.
Regards,
Claudia Tanzer
Enclosure: resume
Tuesday, September 1, 2009
Some more imedical insurance terms
AMBULATORY SURGERY-Surgery done in the doctor's office or at a surgical center, and not requiring an overnight stay.
CARVE-OUT POLICY-A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.
CLAIM-A record of medical services provided to a patient and submitted by the provider to the insurance company for payment.
CPT-4-A 5-digit code that applies to medical services.
FEE SCHEDULE-A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.
ICD-9-A 3 to 5-digit number code describing a diagnosis or medical procedure.
INPATIENT-A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.
OUTPATIENT-A patient who receives health care services, but not admitted to a hospital during a 24-hour period.
PRIMARY CARE PHYSICIAN-A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist(or secondary care physician) or admits them to the hospital.
SUBSCRIBER-A person who enrolls in a health care plan and agrees to pay for premiums , co-payments and deductibles that are part of the plan.
TREATING PHYSICIAN-A physician who provides care to the patient while in the hospital,an usually works a the hospital or comes in as a specialist.
CARVE-OUT POLICY-A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.
CLAIM-A record of medical services provided to a patient and submitted by the provider to the insurance company for payment.
CPT-4-A 5-digit code that applies to medical services.
FEE SCHEDULE-A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.
ICD-9-A 3 to 5-digit number code describing a diagnosis or medical procedure.
INPATIENT-A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.
OUTPATIENT-A patient who receives health care services, but not admitted to a hospital during a 24-hour period.
PRIMARY CARE PHYSICIAN-A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist(or secondary care physician) or admits them to the hospital.
SUBSCRIBER-A person who enrolls in a health care plan and agrees to pay for premiums , co-payments and deductibles that are part of the plan.
TREATING PHYSICIAN-A physician who provides care to the patient while in the hospital,an usually works a the hospital or comes in as a specialist.
Some medical insurance terms.
ANCILLARY PROVIDERS-Services over and above physician services, including laboratory,radiology, home health and skilled nursing facilities.
AUTHORIZATION-Approval of care required before a service is provided. Pre-authorization may be necessary before hospital admission, or before care is given by non-HMO providers.
BALANCE BILLING-Billing a patient for charges not paid by their insurance plan because the charges are above the usual and customary rate or because the insurer considered a procedure medically unnecessary.
CLAIMS REVIEW-The method by which a patient's health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.
COINSURANCE-A provision which limits the amount of the coverage paid by an insurance plan to a certain percentage, with the remaining costs paid by the member.
CO-PAYMENT-The portion of a claim that a member must pay out-of-pocket.
DEDUCTIBLE-The amount an insured member must pay before the insurance company pays benefit.
EOB(EXPLANATION OF BENEFITS)-A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid.
EXCLUSION-Services or supplies not covered under a health plan.
IN-NETWORK PROVIDER-Physicians and other service providers who are contracted with a managed care plan.
OUT-OF-NETWORK PROVIDER-Physicians who are not contracted with a managed care plan.
PROVIDER-A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.
PRE-CERTIFICATION-Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.
REFERRAL AUTHORIZATION-Approval for a member to see a physician or access services outside of the participating medical group.
REFERRAL PHYSICIAN-A physician who sees a patient after another doctor has sent them for specialty care or services.
REFERRING PHYSICIAN-A physician who sends a patient to another doctor for specialty care or services.
AUTHORIZATION-Approval of care required before a service is provided. Pre-authorization may be necessary before hospital admission, or before care is given by non-HMO providers.
BALANCE BILLING-Billing a patient for charges not paid by their insurance plan because the charges are above the usual and customary rate or because the insurer considered a procedure medically unnecessary.
CLAIMS REVIEW-The method by which a patient's health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.
COINSURANCE-A provision which limits the amount of the coverage paid by an insurance plan to a certain percentage, with the remaining costs paid by the member.
CO-PAYMENT-The portion of a claim that a member must pay out-of-pocket.
DEDUCTIBLE-The amount an insured member must pay before the insurance company pays benefit.
EOB(EXPLANATION OF BENEFITS)-A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid.
EXCLUSION-Services or supplies not covered under a health plan.
IN-NETWORK PROVIDER-Physicians and other service providers who are contracted with a managed care plan.
OUT-OF-NETWORK PROVIDER-Physicians who are not contracted with a managed care plan.
PROVIDER-A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.
PRE-CERTIFICATION-Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.
REFERRAL AUTHORIZATION-Approval for a member to see a physician or access services outside of the participating medical group.
REFERRAL PHYSICIAN-A physician who sees a patient after another doctor has sent them for specialty care or services.
REFERRING PHYSICIAN-A physician who sends a patient to another doctor for specialty care or services.
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