HEALTH INSURANCE CAREER OppORTUNITIES

According to the Occupational Outlook Handbook published by the U.S.
Department of Labor—Bureau of Labor Statistics, healthcare facilities and insurance
companies will hire claims examiners (health insurance specialists) to
process routine medical claims at an increased rate of 9 to 17 percent through
the year 2014.

Health insurance specialists (or reimbursement specialists) review health-related claims
to determine the medical necessity for procedures or services performed before
payment (reimbursement) is made to the provider. A claims examiner employed
by a third-party payer reviews health-related claims to determine whether the
charges are reasonable and for medical necessity. Medical necessity involves linking
every procedure or service code reported on the claim to an ICD-9-CM condition
code that justifies the necessity for performing that procedure or service.


The claims review process requires verification of the claim for completeness
and accuracy and comparison with third-party payer guidelines (e.g., expected
treatment practices) to (1) authorize appropriate payment or (2) refer the claim
to an investigator for a more thorough review. A medical assistant is employed
by a provider to perform administrative and clinical tasks that keep the office
or clinic running smoothly. Medical assistants who specialize in administrative
aspects of the profession answer telephones, greet patients, update and file
patient medical records, complete insurance claims, process correspondence,
schedule appointments, arrange for hospital admission and laboratory services,
and manage billing and bookkeeping.


eXAMPLe 1: Procedure: Knee x-ray
Diagnosis: Shoulder pain
In this example, the provider is not reimbursed because the reason for
the x-ray (shoulder pain) does not match the type of x-ray performed
(knee). For medical necessity, the provider would need to document a
diagnosis such as “fractured patella (knee bone).”


eXAMPLe 2: Procedure: Chest x-ray
Diagnosis: Severe shortness of breath
In this example, the provider is reimbursed because medical necessity
for performing the procedure is demonstrated.

Coding is the process of assigning ICD-9-CM and CPT/HCPCS codes to diagnoses,
procedures, and services. Coding systems include:

● International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
(coding system used to report diagnoses and reasons for encounters, such as an
annual physical examination, on outpatient and physician office claims)
● Healthcare Common Procedure Coding System (HCPCS, pronounced “hick picks”), which
consists of two levels:
● Current Procedural Terminology (CPT) (coding system published by the American
Medical Association that is used to report (1) procedures and services performed
during outpatient and physician office encounters and (2) professional
services provided to inpatients)
● HCPCS level II codes (or national codes) (coding system published by CMS that is
used to report procedures, services, and supplies not classified in CPT)
In addition to an increase in insurance specialist positions available in healthcare
practices, opportunities are also increasing in other settings, and include:
● Claims benefit advisors in health, malpractice, and liability insurance companies.
● Coding or insurance specialists in state, local, and federal government agencies,
legal offices, private insurance billing offices, and medical societies. Medical billing
and insurance verification specialists in healthcare organizations.
● Educators in schools and companies specializing in medical office staff training.
● Writers and editors of health insurance textbooks, newsletters, and other publications.
● Self-employed consultants who provide assistance to medical practices with billing
practices and claims appeal procedures.
● Consumer claims assistance professionals, who file claims and appeal low reimbursement
for private individuals. In the latter case, individuals may be dissatisfied
with the handling of their claims by the healthcare provider’s insurance staff.
● Practices with poorly trained health insurance staff who are unwilling or unable to
file a proper claims appeal.
● Private billing practices dedicated to claims filing for elderly or disabled patients.