Medical Billing Professional - Course Outline

UNIT I

SECTION 1 - WHO PAYS AND WHO BENEFITS

• The billing and reimbursement process is intensely complex.

• Understanding medical terminology employed.

SECTION 2 – PROVIDER STRUCTURE AND PROTOCOLS

• The Provider’s staff and their responsibilities

• Basic practice elements like payment policies etc.

• The patient and the registration process

SECTION 3 – HOSPITAL BILLING

• Types of hospital billing: Outpatient, Inpatient and Combination.

• Various billing functions

SECTION 4 – FAMILY RELATIONSHIPS

• Integration of information gathered

SECTION 5 – BILLING THE ENCOUNTER

• What is a Superbill?

• Data entry, pre-billing protocols Insurance forms and claims processing

• Payments and adjustments

• Appeal process and statements.

SECTION 6 – PRACTICE ECONOMICS

• Different types of reports.

• Steps to overcome delinquency in payments

SECTION 7 – COLLECTIONS

• Managing receivables

• Necessity of monitoring accounts on a regular basis

SECTION 8 – CODING

• Two main types of coding systems – CPT and ICD

• Coding guidelines and coding summary

• Coding software

SECTION 9 – FEE PROFILES

• Determining attendant fees

• Advantages of CPT system

• Role of Insurance companies and Physician’s fee schedule

SECTION 10 – OVERVIEW OF MEDICAID – MEDICARE

• CMS and its functioning HIPAA – Health Insurance Reform and Administrative Simplification

•  Medicare’s EDI and its advantages

UNIT 2

Section 1 – The Health Insurance Specialist

• Basic skill requirements and job description of Health Insurance Specialist

• About ICD 9 (CM) and ICD 10 (CM), their codes and manuals

• HCPCS (Healthcare Common Procedure Coding System

Section 2 – Billing Terminology

• Commonly used terms in this field

• Evolution of US Healthcare legislation

• Different types of Insurance

• Different types of payment systems used

Section 3 – Healthcare Organization Plans

• Commonly used terms in this field

• Various Healthcare organizations like MCO

Section 4 – Insurance claims

• Actual insurance processing steps

• Place and type of service codes

• Form filling

Section 5 – Payer Processing

• Processing claims, errors and denials

• Insurance regulation

Section 6 – Laws, Rules and Regulations

• Federal, government and state legislations

• Commonly used terminology

• Laws regarding privacy HIPAA - Health insurance portability and accountability act

• Fraud and abuse

Section 7 – Private Insurers

• Blue Cross and Blue Shield, a primary Insurance Company

• Different plans and billing rules under this company

Section 8 – Medicare

• About Medicare: its programs and types of coverage

• Medicare Summary Notice

Section 9 – Medicaid

• Various eligibility groups having federal matching funds

• Provider confirmation of eligibility

• Covered Service and billing information

• Filing claims

Section 10 – Tricare

• About Tricare and its Service centers

• CHAMPVA (Civilian Health and Medical Program, Department of Veteran Affairs)

• Billing protocol and exceptions

Section 11 – Worker’s Compensation

• Commonly used terminology

• Various programs for Worker’s compensation; federal and state Provider rules

• Claims forms

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