Medical Billing Specialist

Hours: 330 / Access Length: 12 Months / Delivery: Online, Self-Paced
Retail Price: $1,780.00

Course Overview:

With the Medical Billing Career Prep program, you will gain the skills you need to enter one of the fastest-growing fields in allied health as a medical billing specialist. In this program, you will gain hands-on, practical experience working with the main coding manuals in the field, the ICD-10-CM and the CPT. In addition; you will be introduced to ICD-10-CM. You will also master the legal, ethical, and regulatory concepts that are central to this field. Upon completion of this program, you will be ready to begin your career in an entry-level position.

Students will:

• Explain the role and responsibilities of an insurance billing specialist within various healthcare settings. 
• Analyze the impact of HIPAA privacy and security regulations on medical billing practices and healthcare organizations. 
• Differentiate between compliance, fraud, and abuse in medical billing and evaluate regulatory measures used to prevent violations. 
• Compare and contrast different health insurance plans, including coverage structures, policy terms, and cost-sharing responsibilities. 
• Evaluate the unique requirements and challenges associated with government insurance programs such as Medicare, Medicaid, TRICARE, and state-specific plans. 
• Demonstrate an understanding of diagnostic and procedural coding systems, including ICD-10-CM, CPT, and HCPCS Level II. 
• Interpret key components of medical claims processes, including the use of paper and electronic claim forms in healthcare reimbursement. 
• Assess the revenue cycle in healthcare, including payment processing, claim adjudication, and problem-solving for denied claims. 
• Identify best practices for managing patient payments, outstanding balances, and legal considerations in healthcare collections. 
• Recognize career opportunities in medical billing and coding and describe the skills necessary for professional growth, certification, and job attainment.

Course Outline:

Lesson 1: Role of an Insurance Billing Specialist

This lesson covers the role of an insurance billing specialist in various healthcare settings, focusing on accurate claims submission, coding, and billing procedures. Through case-based exercises, you will develop proficiency in handling claim denials, correcting patient information errors, and navigating professional and ethical considerations essential for success in medical billing and reimbursement.

Lesson 2: Privacy, Security, and HIPAA

This lesson examines HIPAA compliance through real-world case studies of violations and their resolutions. You will analyze how privacy and security failures impact healthcare organizations, the consequences of noncompliance, and strategies for remediation. The lesson also covers how state privacy laws interact with HIPAA, shaping compliance requirements across different jurisdictions.

Lesson 3: Compliance, Fraud, and Abuse

This lesson focuses on compliance, fraud, and abuse in medical billing, using real-world cases to illustrate key differences. You will examine common fraudulent practices, regulatory measures like the False Claims Act, and enforcement programs that monitor violations. A mock compliance audit example will provide the steps in detecting and preventing billing errors.

Lesson 4: Basics of Health Insurance

This lesson explores the history and evolution of health insurance, providing context for modern coverage structures. You will learn to compare insurance plans, interpret policy terms, and analyze cost-sharing responsibilities. Through real-world scenarios, you will practice identifying key components of insurance policies and determining coverage implications for patients and providers.

Lesson 5: The Blue Plans, Private Insurance, and Managed Care Plans

This lesson covers the financial and operational differences between private and public insurance, focusing on provider networks and reimbursement negotiations. You will learn to interpret insurance contracts, evaluate how payment structures shape provider decisions, and determine the impact of network agreements on patient costs and access to care.

Lesson 6: Medicare

In this lesson, you will extract key details from Medicare insurance cards, determine provider participation options, and apply Medicare-specific reimbursement models. You will also learn to follow claim submission timelines, process overpayment corrections, and interpret recent legislative updates that affect Medicare policies and provider payments.

Lesson 7: Medicaid and Other State Programs

In this lesson, you will evaluate state-specific Medicaid policies, determine how expansion impacts access to care, and interpret how Medicaid integrates with programs like CHIP and SNAP. You will also develop skills in navigating provider enrollment, understanding state-level reimbursement models, and identifying how funding differences affect patient coverage and services.

Lesson 8: TRICARE and Veterans Health Care

In this lesson, you will learn to apply military-specific billing regulations, handle claims for active-duty and retired service members, and manage referrals within TRICARE and Veterans Health Administration systems. You will also practice identifying provider classifications, calculating patient cost-sharing for military beneficiaries, and addressing access challenges unique to veterans through real-world case examples.

Lesson 9: Workers’ Compensation, Automobile, and Liability Insurance

This lesson provides an overview of workers’ compensation, automobile, and liability insurance. You will identify eligibility requirements, classify types of claims, and recognize key reporting forms. Additionally, you will examine employer and insurer responsibilities, understand fee schedules, and explore processes for managing fraud investigations, coordinating benefits, and addressing out-of-state claims.

Lesson 10: Disability Income Insurance and Disability Benefit Programs

This lesson explains how to verify eligibility for federal, state, and private disability income programs, interpret benefit amounts based on policy terms, and identify required documentation for claims. You will also review waiting periods, benefit structures, and the processes involved in submitting disability claims across different programs.

Lesson 11: Medical Documentation and the Electronic Health Record

In this lesson, you will examine the structure of electronic health records, identify required medical documentation, and recognize common errors that affect billing accuracy. This lesson covers legal standards for record retention, provider responsibilities in documentation, and the processes used to review and audit medical records for compliance and accuracy.

Lesson 12: ICD-10-CM Coding

In this lesson, you will review diagnostic coding and understand interpreting ICD-10-CM guidelines and applying conventions to accurately code diagnoses. You'll learn to sequence diagnosis codes, ensuring each aligns with established medical necessity, and effectively utilize coding manuals. This session also introduces the distinctions between outpatient and inpatient coding requirements, enhancing your coding precision across different medical settings.

Lesson 13: CPT Coding

This lesson guides you through interpreting CPT coding conventions and recognizing procedure code categories, including E/M services, surgery, radiology, and laboratory codes. This lesson covers the use of code modifiers, identification of bundled services, and common coding errors. You will also explore surgical, radiology, and laboratory coding and examine how procedural codes influence reimbursement.

Lesson 14: HCPCS Level II Coding

In lesson 14 you will explore the HCPCS Level II coding system, focusing on categories like durable medical equipment, drugs, and transportation services. This lesson guides you in using the HCPCS manual, applying correct code modifiers, and referencing the Table of Drugs and Biologicals for accurate code selection.

Lesson 15: The Paper Claim CMS 1500

This lesson covers the CMS-1500 paper claim form, including its purpose, required fields, and when paper submissions are necessary. It outlines claim types, processing steps, and common errors that lead to rejections. The lesson breaks down each section of the form, detailing how to enter provider, patient, and insurance information accurately.

Lesson 16: The Electronic Claim

This lesson explains the structure of electronic claims, the role of clearinghouses, and how data is transmitted securely. It covers transaction and code set regulations, unique provider and patient identifiers, and the use of electronic remittance advice. You will examine common processing errors, troubleshoot methods, and the benefits of electronic claims over paper submissions.

Lesson 17: Receiving Payments and Insurance Problem-Solving

This lesson covers the revenue cycle management process, including claim submission, adjudication, and reimbursement timelines. It explains how to interpret explanation of benefits (EOB) documents, manage secondary insurance claims, and identify common claim errors. The lesson also explores strategies for handling denied claims, filing appeals, and working with Medicare, TRICARE, and state insurance commissioners to resolve payment issues.

Lesson 18: Collection Strategies

In this lesson, you will examine how to manage payments, track outstanding balances, and handle missed payments in a healthcare setting. You will learn about different billing methods, fee adjustments, and legal requirements for collections. The lesson also guides you through strategies for communicating with patients about payments, resolving disputes, and addressing unpaid debts through collection agencies or legal action.

Lesson 19: Introduction to Health Care Facilities and Ambulatory Surgery Centers

In this lesson, you explore the structure of healthcare facilities, the differences between inpatient and outpatient services, and the regulations that impact operations. This lesson covers how reimbursement systems determine payment for services, including prospective payment models and insurance billing processes. You will also review quality reporting requirements and policies that influence patient care standards.

Lesson 20: Billing for Health Care Facilities

In lesson 20, you learn how professional, outpatient, and inpatient billing differ, along with the coding systems and claim forms used for each. This lesson covers selecting principal diagnoses and procedures, understanding the structure of ICD-10-PCS codes, and applying official coding guidelines. The CMS-1450 (UB-04) form is also introduced, detailing its sections and how it is used for facility claims.

Lesson 21: Seeking a Job and Attaining Professional Advancement

The final lesson will explore career opportunities in medical billing and coding, including job search strategies, professional certifications, and networking for advancement. This lesson covers resume writing, interview preparation, and proper application techniques. You will also learn about self-employment considerations, business planning, and the benefits of joining professional organizations.

All necessary course materials are included.

System Requirements:

Internet Connectivity Requirements:

• Cable, Fiber, DSL, or LEO Satellite (i.e. Starlink) internet with speeds of at least 10mb/sec download and 5mb/sec upload are recommended for the best experience.

NOTE: While cellular hotspots may allow access to our courses, users may experience connectivity issues by trying to access our learning management system.  This is due to the potential high download and upload latency of cellular connections.   Therefore, it is not recommended that students use a cellular hotspot as their primary way of accessing their courses.

Hardware Requirements:

• CPU: 1 GHz or higher
• RAM: 4 GB or higher
• Resolution: 1280 x 720 or higher.  1920x1080 resolution is recommended for the best experience.
• Speakers / Headphones
• Microphone for Webinar or Live Online sessions.

Operating System Requirements:

• Windows 7 or higher.
• Mac OSX 10 or higher.
• Latest Chrome OS
• Latest Linux Distributions
  

NOTE: While we understand that our courses can be viewed on Android and iPhone devices, we do not recommend the use of these devices for our courses. The size of these devices do not provide a good learning environment for students taking online or live online based courses.

Web Browser Requirements:

• Latest Google Chrome is recommended for the best experience.
• Latest Mozilla FireFox
• Latest Microsoft Edge
• Latest Apple Safari

Basic Software Requirements (These are recommendations of software to use):

• Office suite software (Microsoft Office, OpenOffice, or LibreOffice)
• PDF reader program (Adobe Reader, FoxIt)
• Courses may require other software that is described in the above course outline.