DACUM

For Statewide DACUM information http://www.healthoccupations.org/dacum.cfm

DACUM Competency Profile for Medical Reimbursement Specialist

March 2-3, 1999

SPONSORS DACUM CHART DACUM PANEL GENERAL SKILLS WORKER CHARACTERISTICS TOOLS & EQUIPMENT FUTURE TRENDS

Sponsored by the Regional Health Occupations Resource Centers:

North & Far North Region Butte College	Los Angeles County Region Mt. San Antonio Community College	RHORC Leadership Sacramento City College
Central Region Hartnell College	Orange County Region Saddleback College
Bay Region Mission College	South Coast Region Santa Barbara City College

Health Care Industry Partners:

Health South Sacramento	Produced by the Regional Health Occupations Resource Center
Sansum/Santa Barbara Medical Foundation Clinic	South Coast Region Santa Barbara City College

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DACUM CHART for Medical Reimbursement Specialist:

A medical reimbursement specialist is a member of the financial management team who ensures that maximum reimbursement is obtained through coding, billing, and collecting for all services rendered.

DUTIES and TASKS

A Maintain reimbursement office operations.

A-1 Implement opening procedures.
A-2 Schedule billing office staff.
A-3 Maintain billing office supplies.
A-4 Process office mail.
A-5 Update patient demographic information.
A-6 Update patient eligibility information.
A-7 Maintain medical records documentation.
A-8 Process legal documents.
A-9 Coordinate billing software support.
A-10 Develop and maintain policies and procedures.
A-11 Update government payor information. A-12 Maintain current payor information.
A-13 Assess billing office equipment needs. A-14 Implement closing procedures.

B Obtain service authorizations and precertifications.

B-1 Review documentation to determine need for authorization.
B-2 Complete authorization request forms.
B-3 Contact authorization referral entities.
B-4 Obtain service precertification or predetermination of medical necessity.
B-5 Submit service predetermination documentation. B-6 Submit processed authorization to third party payor.
B-7 Respond to denied authorizations.
B-8 Maintain authorization and precertification files.

C Code procedures and diagnoses.

C-1 Review charts for documentation to support charges and services.
C-2 Analyze source documentation to determine diagnoses.
C-3 Identify procedure code(s).
C-4 Identify procedure modifier (s).
C-5 Analyze most comprehensive combination of procedure codes.
C-6 Select CPT code(s) for maximal reimbursement.*
C-7 Identify diagnostic code(s).
C-8 Select most specific diagnostic code(s).
C-9 Reconcile diagnostic code(s) to procedure code(s).
C-10 Refer incomplete documentation to service provider or receptionist for completion.

D Post charges for services.

D-1 Review charge tickets for completion.
D-2 Enter charge ticket data.
D-3 Batch charge tickets.
D-4 Balance batch charges.
D-5 File completed batches.
D-6 Post charge adjustments to journal.

E Process insurance billing.

E-1 Verify "clean claim" status.
E-2 Verify electronic status of claims.
E-3 Sort paper claims according to third party payor.
E-4 Format claim to conform to third party payor requirements.
E-5 Attach required documentation.
E-6 Submit claim to appropriate payor location.
E-7 Revise rejected electronic claims.
E-8 Resubmit revised electronic claim.
E-9 Determine secondary payor status.
E-10 Process secondary claims.

F Post payment and adjustments.

F-1 Sort payment receivables.
F-2 Review EOBs and RAs for payments and adjustments.*
F-3 Post line item payments to corresponding charges.
F-4 Calculate payment adjustments.
F-5 Enter payment adjustment.
F-6 Balance payment totals to entered payment data.
F-7 Determine patient's financial responsibility.
F-8 Generate statement to patient and/or to secondary payor.
F-9 Prepare bank deposits.
F-10 Enter deposits into accounting system.
F-11 Contact third party payor to resolve payment discrepancies.
F-12 Generate checks for over payments.

G Respond to patient inquires.

G-1 Determine purpose of inquiry.
G-2 Research information sources.
G-3 Explain insurance benefits to patient.
G-4 Clarify office policies and procedures to patient.
G-5 Contact payor on behalf of patient.
G-6 Inform patient of outcome.
G-7 Arrange current account payment plans. G-8 Serve as patient advocate.
G-9 Refer patient to additional information sources.

H Resolve claim problems with third party payors.

H-1 Review third party aged accounts.
H-2 Contact payor for claim status.
H-3 Provide requested information.
H-4 Clarify provider's documentation.
H-5 Contact patient to verify information.
H-6 Resubmit revised claim.
H-7 Submit denied claims to review or appeals department.
H-8 Contact provider relations representative for assistance.

I Analyze patient aged accounts.

I-1 Generate patient aged account report.
I-2 Review patient past due accounts.
I-3 Request outstanding balance from patient.
I-4 Determine patient payment arrangements.
I-5 Refer outstanding accounts to collection dept/agency.
I-6- Change account to reflect patient's new financial status.

J Maintain reimbursement information.

J-1 Track payor reimbursement trends.
J-2 Determine importance of each payor to practice.
J-3 Analyze contractual adjustment rate of potential payors.
J-4 Network with reimbursement peers to share information.
J-5 Educate staff on payor changes and updates.
J-6 Participate in continuing ed. on reimbursement regulations.
J-7 Serve on facility reimbursement committee.

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DACUM Panel

Nancy Campbell, C.M.A, B.S.H.M. Coder/Biller R.K. Otani, M.D. and J.B. Moo, M.D. Chico and Instructor, Butte College Chico

Esther Elias, A.A. Program Consultant Regional Health Occupations Resource Center Mt. San Antonio College Whittier

Billie Jo Espitia, Voc. Ed. Teaching Credential Office Manager/Billing Roy Egari, M.D. Artesia

Susanne Schragl French Manager of Registration/Patient Accounts Sansum/Santa Barbara Medical Foundation Clinic Santa Barbara

Diane Galloway, Administrative Health Services Certificate Insurance Specialist Limberg Eye Surgery San Luis Obispo

Chris McNamara, M.P.H. Director, Business Services Sansum/Santa Barbara Medical Foundation Clinic Santa Barbara

Berta Powers, C.M.A. Financial Manager El Camino Urology Mountain View

Nancy Shearer Billing Supervisor Health South Sacramento

Additional Participant

Sue Watkins, R.R.A., C.T.R. Coordinator, Regional Health Information Technician Program Santa Barbara City College

DACUM Facilitators

Marsha Roberson, R.N., M.N. Director, Regional Health Occupations Resource Center Santa Barbara City College

Linda Zorn, R.D., M.S. Director, Regional Health Occupations Resource Center Butte College

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General Knowledge and Skills

CPT codes- modifiers ICD9 codes HCPCS codes Communication Verbal Written Composition (letters) Accounting software HCFA1500 forms UB92 forms Bundle/unbundling skills Problem solving and prioritization Accounting Anatomy Terminology- medical and insurance Global periods Components of supporting documentation Histories and physicals Keyboard/ten key Freshman English Working knowledge of capitation Working knowledge of Medicare regulations Working knowledge of MediCal regulations

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Worker Characteristics

Honest Courteous Ethical Detail-oriented Assertive Responsible Multi-tasked Team player Flexible Professional Self-motivated Problem solver Organized Customer service oriented

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Tools, Equipment Supplies & Materieals

UB92/HCFA forms Quickbooks software Shredder Computer hardware with modem Computer program for medical office management Typewriter Office machines- FAX, copier CPT book RBRVs book ICD9 book Code link- book or software Point of service device Medicare and MediCal manuals 10-key calculator

Future Trends and Concerns

Medical Reimbursement Specialist should be recognized as the person the MD works with to assure the operation is profitable Computerized records Fast growth profession Nationalized medicine/single payor Mergers, change in number of health maintenance organizations (HMOs)

This project was funded by Economic Development grant #98-0226, implemented by the Regional Health Occupations Resource Centers and monitored by the Chancellor's Office, California Community Colleges. Permission is hereby granted to reproduce this work, in whole, or part, for classroom or curriculum use only.

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