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