Certified Medical Insurance Specialist (CMIS)

CMIS evening classes, 530P-8P for 6 days (Mondays/Wednesdays, January 14, 16, 21, 23, 28, 30
4-hour exam on a Saturday, February 2, 9A-2P)
$999.00 per student

Understand payer models and rules for accurate claim filing and reimbursement.

This certification program explores the current landscape of third-party reimbursement. Detailed lectures,

course materials and examples will teach participants how to effectively expedite claims, secure timely, correct reimbursement, and protect the financial interest of the practice.

Course Outline:

Role 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 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

ICD-10-CM Diagnostic Coding

  • The purpose and importance of coding diagnoses to the highest level of specificity
  • Features and use of ICD-10-CM code book 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 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
  • Detailed look at the new CMS-1500 and what each section contains
  • 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

  • Learn the transaction & code set standards used 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 disability is considered temporary or permanent
  • State eligibility requirements, benefits, and limitations of SSDI and SSI

To register or request additional information

Contact Joanne Rose at 903-823-3384, email joanne.rose@texarkanacollege.edu or call toll free 1-888-963-5967.