JOB RESPONSIBILITIES FOR HEALTH INSURANCE

This section provides an overview of the major responsibilities delegated to
health insurance specialists. In practices where just one or two persons work
with insurance billing, each individual must be capable of performing all the
listed responsibilities. In multispecialty practices that employ many health
insurance specialists, each usually processes claims for a limited number of
insurance companies (e.g., an insurance specialist may be assigned to processing
only Medicare claims). Some practices have a clear division of labor, with
specific individuals accepting responsibility for only a few assigned tasks.
Typical tasks are listed in the following job description.


Health Insurance Specialist Job Description
1. Review patient record documentation to accurately code all diagnoses,
procedures, and services using ICD-9-CM for diagnoses and CPT and
HCPCS level II for procedures and services.

The accurate coding of diagnoses, procedures, and services rendered to
the patient allows a medical practice to
● Communicate diagnostic and treatment data to a patient’s insurance plan to
assist the patient in obtaining maximum benefits.
● facilitate analysis of the practice’s patient base to improve patient care delivery
and efficiency of practice operations to contain costs.
2. Research and apply knowledge of all insurance rules and regulations for
major insurance programs in the local or regional area.
3. Accurately post charges, payments, and adjustments to patient accounts
and office accounts receivable records.


4. Prepare or review claims generated by the practice to ensure that all
required data are accurately reported and to ensure prompt reimbursement
for services provided (contributing to the practice’s cash flow).
5. Review all insurance payments and remittance advice documents to
ensure proper processing and payment of each claim. The patient
receives an explanation of benefits (EOB), which is a report detailing the
results of processing a claim (e.g., payer reimburses provider $80 on a
submitted charge of $100). The provider receives a remittance advice (or
remit), which is a notice sent by the insurance company that contains payment
information about a claim. (EOBs and remits are further discussed
in Chapter 4.)
6. Correct all data errors and resubmit all unprocessed or returned claims.
7. Research and prepare appeals for all underpaid, unjustly recoded, or
denied claims.
8. Rebill all claims not paid within 30 to 45 days, depending on individual
practice policy and the payers’ policies.
9. Inform healthcare providers and staff of changes in fraud and abuse laws,
coding changes, documentation guidelines, and third-party
payer requirements that may affect the billing and claims submission
procedures.
10. Assist with timely updating of the practice’s internal documents, patient
registration forms, and billing forms as required by changes in coding or
insurance billing requirements.
11. Maintain an internal audit system to ensure that required pretreatment
authorizations have been received and entered into the billing and treatment
records. Audits comparing provider documentation with codes
assigned should also be performed.
12. Explain insurance benefits, policy requirements, and filing rules to
patients.
13. Maintain confidentiality of patient information.
Scope of Practice and Employer Liability
Regardless of the employment setting, health insurance specialists are guided
by a scope of practice that defines the profession, delineates qualifications and
responsibilities, and clarifies supervision requirements (Table 1-2). Health
insurance specialists who are self-employed are considered independent contractors.
The ’Lectric Law Library’s Lexicon defines an independent contractor as “a
person who performs services for another under an express or implied agreement
and who is not subject to the other’s control, or right to control, of the
manner and means of performing the services. The organization that hires an
independent contractor is not liable for the acts or omissions of the independent
contractor.”


Independent contractors should purchase professional liability insurance (or
errors and omissions insurance), which provides protection from claims that contain
errors and omissions resulting from professional services provided to clients as
expected of a person in the contractor’s profession. Professional associations
often include a membership benefit that allows purchase of liability insurance
coverage at reduced rates.

Scope of practice for health insurance specialists

Definition of Profession: One who interacts with patients to clarify health insurance coverage
and financial responsibility, completes and processes insurance
claims, and appeals denied claims.

Qualifications: Graduate of health insurance specialist certificate or degree program
or equivalent. One year of experience in health insurance or related
field. Detailed working knowledge and demonstrated proficiency in
at least one insurance company’s billing and/or collection process.
Excellent organizational skills. Ability to manage multiple tasks in a
timely manner. Proficient use of computerized registration and billing
systems and personal computers, including spreadsheet and word
processing software applications. Certification through AAPC, AHIMA,
or AMBA.

Responsibilities: Use medical management computer software to process health
insurance claims, assign codes to diagnoses and procedures/
services, and manage patient records. Communicate with patients,
providers, and insurance companies about coverage and reimbursement
issues. Remain up-to-date regarding changes in healthcare
industry laws and regulations.
Supervision
Requirements:
Active and continuous supervision of a health insurance specialist is
required. However, the physical presence of the supervisor at the time
and place responsibilities are performed is not required

 Scope of practice for health insurance specialists

EXAMPLe: Linda Starling is employed by Dr. Pederson’s office as
a health insurance specialist. As part of her job, Linda has access to
confidential patient information. While processing claims, she notices
that her mother-in-law has been a patient, and she later tells her husband
about the diagnosis and treatment. Her mother-in-law finds out
about the breach of confidentiality and contacts her lawyer. Legally, Dr.
Pederson can be sued by the mother-in-law. Although Linda could also
be named in the lawsuit, it is more likely that she will be terminated.
EXAMPLE: The American Health Information Management Association
makes information about the purchase of a professional liability plan
available to its membership. If a member is sued for malpractice, the
plan covers legal fees, court costs, court judgments, and out-of-court
settlements. The coverage includes up to $2 million per incident and up
to $4 million in any one policy year.










Bonding insurance An insurance agreement that guarantees repayment for financial losses resulting from an employee’s act or
failure to act. It protects the financial operations of the employer.

Business liability insurance
Protects business assets and covers the cost of lawsuits resulting from bodily injury (e.g., customer
slips on wet floor), personal injury (e.g., slander or libel), and false advertising. Medical malpractice
insurance is a type of liability insurance, which covers physicians and other healthcare professionals
for liability as to claims arising from patient treatment.
Property insurance Protects business contents (e.g., buildings and equipment) against fire, theft, and other risks.

Workers’ compensation insurance
Protection mandated by state law that covers employees and their dependents against injury and death
occurring during the course of employment. Workers’ compensation is not health insurance, and it is not intended to compensate for disability other than that caused by injury arising from employment. Thepurpose of workers’ compensation is to provide financial