Chapter 1: Health Insurance Specialist Career

AACP

professional association, previously known as the American Academy of Professional Coders, established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding

American Association of Medical Assistants(AAMA)

enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants’ right to practice

American Health Information Management Association(AHIMA)

founded in 1928 to improve the quality of medical records, and currently advances the health information management(HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and IDC-10-PCS in 2013

American Medical Billing Association(AMBA)

provides industry and regulatory education and networking opportunities for members and offers the Certified Medical Reimbursement Specialist(CMRS) credential

Bonding Insurance

an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee- protects the financial operations of the employer

Business Liability Insurance

protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising

Centers for Medicare and Medicaid Services(CMS)

formerly known as the Health Care Financing Administration(HCFA); an administrative agency within the federal Department of Health and Human Services(DHHS)

Claims Examiner

employed by third-party payers to review health-related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis

Coding

process of reporting diagnoses, procedures, services, and supplies as numeric and alphanumeric characters(called codes) on the insurance claim

Current Procedural Terminology(CPT)

published by the American Medical Association; includes five-digit numeric codes and descriptors for procedures and services performed by providers (e.g., 99203 identifies a detailed office visit for a new patient)

Embezzle

the illegal transfer of money or property as a fraudulent action; to steal money from an employer

Ethics

principle of right or good conduct; rules that govern the conduct of members of a profession

HCPCS Level ll Codes

national codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT

Health Care Provider

physician or other health care practitioner

Health Information Technicians

professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients

Health Insurance Claim

documentation that is electronically or manually submitted to an insurance plan requesting reimbursement for health care procedures and services provided (e.g., CMS-1500 and UB-04 claims)

Health Insurance Specialists

person who reviews health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist

Healthcare Common Procedure Coding System(HCPCS)

coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System

Hold Harmless Clause

policy that the patient is not responsible for paying what the insurance plan denies

Independent Contractor

defined by the ’Lectric Law Library’s Lexicon 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.”

International Classification of Diseases, 10th Revision, Clinical Modification(ICD-10CM)

coding system to be implemented on October 1, 2015, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters

International Classification of Diseases, 10th Revision, Procedural Coding System(ICD-10-PCS)

coding system to be implemented on October 1, 2015, and used to report procedures and services on inpatient claims

Internship

non-paid professional practice experience that benefits students and facilities that accept students for placement; students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment

Medical Assistant

employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly

Medical malpractice Insurance

a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment

Medical Necessity

involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service

National Codes

commonly referred to as HCPCS Level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered)

Professional Liability Insurance

provides protection from liability as a result of errors and omissions when performing their professional services; also called errors and omissions insurance

Professionalism

conduct or qualities that characterize a professional person

Property Insurance

protects business contents (e.g., buildings and equipment) against fire, theft, and other risks

Respondeat Superior

Latin for “let the master answer”; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment

Scope of Practice

health care services, determined by the state, that an NP and PA can perform

Workers’ Compensation Insurance

insurance program, mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders