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 Insurance and Billing Course - Objectives Part 1 and Part 2 -     StoreFront    

The entire course should take about 12 hours to complete. With the many Internet links and downloadable documents, you could easily spend twice that amount of time. 

The CEU version has additional links and Questions that need to be answered and submitted to Ritecode for CEU credit. 

Part 1

  1. Understand the similarities and differences between the major types of insurance plans.
  2. List the main clerical and administrative tasks that must be carried out if a practice is to receive the maximum payment for services.
  3. Discuss the opportunities for medical office personnel who want to take on more responsibility in solving operational problems that result from the complexity of the claims process.

Module 2

  1. Know the difference between Fee for Service and Capitation Plans.
  2. Know what "Episode of Care" method is.
  3. Understand Preauthorization rules and guidelines.
  4. Know which three coding manuals are required for accurate coding.
  5. Know the importance of a schedule for ordering manuals.

Module 3

  1. Know the physician payment process.
  2. The Critical Pathway Of A Claim
  3. Understand the registration process
  4. Know what a Welcome Packet is.
  5. Know the significance of a financial policy.
  6. Know what registration form is.
  7. Know what a Plan Identification Card is.
  8. Know what  Preauthorization Requirements are.
  9. Know what "Out-of-Pocket Costs" are.
  10. Know what a SuperBill is.

Module 4

  1. Know what comprises an encounter form.
  2. The encounter form

  3. Matching CPT and ICD-9-CM codes on the Encounter Form

  4. Know how to look up ICD-9-CM diagnosis codes which justify payment for certain CPT codes.

  5. Know what “claim edits” are.

  6. Understand what “Medical Necessity” is.

  7. Understand the importance of collecting payments at the time of service.

  8. Know how to post for payments.

  9. Know how to monitoring Claims Reported to the Plan

  10. Know what an Explanation of Benefits (EOB), also known as Remittance Advice is.

  11. Be familiar with the Denial Reason Codes.

  12. Understand the difference between Physician charges for professional services and Hospital charges.

Module 5

  1. Know the importance of written policies/information for registration telephone calls/prescriptions etc…

  2. Sample financial policy information

  3. Credit policy

  4. Insurance Worksheet.

  5. Truth in lending statement

  6. What Open Enrollment is.

  7. Know key terms such as policyholder, dependent, effective date, waiting period

  8. ID Cards, Benefit codes

  9. Exclusions, pre-existing conditions

Module 6

  1. Understand the Claims Processing cycle

  2. Adjudicate a claim

  3. Clean claim

  4. Cutoff date

  5. Cost sharing arrangements

  6. Out of pocket costs

  7. Copayments

  8. Deductibles

  9. Coinsurance

  10. Primary insurer

Module 6 (continued)

  1. Secondary insurers

  2. Coordination of Benefits (COB)

  3. Subrogation

  4. Medical Resource monitoring

  5. Preauthorization

  6. Second opinion

  7. Authorization number

  8. Preauthorization

  9. Participating physician

  10. Non-participating physician

  11. Provider identification numbers

  12. Automatic claim edits

  13. Bundling

  14. Unbundling

  15. Up-coding

  16. Monitoring physician cost

  17. Maximum allowable Fee (MAF)

  18. Usual, Customary, and Reasonable

  19. Resource Based Relative Value Scale (RBRVS)

Part 2

Module 7

  1. Capitation

  2. Utilization management

  3. Physician Peer Review Profiling

  4. Case management

  5. quality improvement.

  6. Preadmission certification (PAC)

 Module 8

  1. Forms

  2. claims reporting rules by plan


  4. Medicare enrollment

  5. Know the difference between Part A (hospital insurance)  and Part B (voluntary medical insurance).

  6. Fiscal intermediaries

  7. DME providers

  8. Medicare Trust Funds  

Module 9

  1. Benefits for Part B

  2. Physician services

  3. Outpatient hospital services

  4. Medicare non-covered services

  5. Not reasonable and necessary (not medically necessary in Medicare's terminology).

  6. Advance Beneficiary Notices (ABN).

  7. Waiver of liability

  8. Level III HCPCS modifier

  9. Understand the term"Reasonable and Necessary"

  10. ID card.

  11. Health Insurance Claim Number (HICN)

  12. Railroad beneficiaries

  13. Understand "Out-of-pocket" costs

Module 10

  1. Medigap coverage

  2. Deficit Reduction Act and the Omnibus Reconciliation Acts (OBRAs)

  3. crossover claims

  4. incident to services

  5. Health Professional Shortage Areas

  6. Employer Group Health Plan (EGHP)

  7. Automobile Liability and Work·Related Injuries

  8. no-fault insurance

  9. CMS 1965 "Request for Hearing" form.

  10. Hearing options

Module 11 

  1. Administrative Law Judges (ALJs)

  2. Social Security Administration (SSA) office

  3. Appeals Council

  4. OIG

  5. DHHS

  6. Know what constitute Fraud and/or Abuse

  7. Four ways to avoid fraud and abuse.

  8. The Freedom of Information Act of 1966

 Module 12

  1. Understand the Medicaid program

  2. Claims reporting

  3. Understand the Medicare to Medicaid Crossover claims process.

1) Sign up by Credit Card or Paypal  

2) Registration Screen - Select "Ins & Billing"

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