Certification Training

Linda D'Spain CMPE, CMC, CMIS, CMOM, CMCO, CMCA-E/M

Linda is President of her medical practice management consulting firm, D'Spain Consulting. She travels the country conducting national seminars, workshops and webinars and consulting with physician practices, hospitals and medical societies on healthcare reimbursement, documentation guidelines, procedural and diagnostic coding, financial management, human resources, medical office management and compliance with fraud and abuse, OSHA, and HIPAA. She has also served as an Independent Review Organization (IRO) for the Office of the Inspector General and consulted for the Texas Medical and Dental Boards.

With more than 30 years of experience in medical practice management, Linda has managed cardiology, cardiothoracic, vascular surgery, physical therapy, orthopedics, pediatric orthopedics, gynecology and reproductive endocrinology and large multispecialty group practices. She maintained broad responsibilities in business and clinical operations, financial management, governance and organizational dynamics, human resource management, marketing, customer service, compliance, information system management, mergers and acquisitions and risk management.

Linda has attained all five PMI certifications. She also has a degree in Business Administration and is a Board Certified Medical Practice Executive through the American College of Medical Practice Executives, a member of the San Antonio Medical Group Managers Association (MGMA) and has served as an advisory board member with PMI.

Learn the current guidelines and responsibilities to manage third-party provider reimbursement. The instructor will explain the types of managed care plans and guidelines for working with third-party payers. Review documentation, diagnostic and procedural coding rules, and compliance. Participants will learn collection strategies, tips, and receive problem-solving guidance.

The CMIS course will guide participants through the first claims pass and includes new reject/denial practice exercises from real cases to help solidify knowledge. Staff will return to the office with a keen understanding of their role and responsibility for protecting practice revenue.

CMIS candidates with less than a year of coding experience should complete the PMI Basics: Introduction to Medical Coding course prior to enrollment.

Required Self-Supplied Materials

The following coding resources are required to study for this course and for use during the exam: current editions of CPT®, HCPCS, ICD-10-CM, and a medical dictionary.

Candidates that schedule their exam in the next calendar year should have updated coding books. Practice Management Institute (PMI) updates the course and exam annually using the current American Medical Association (AMA) CPT® Professional coding manual* as a reference. The AMA CPT® codebook with the official CPT guidelines is recommended for use with this course. Coding books are widely available for purchase or lease through a variety of nationwide publishers and retailers.

*Recommendation and use of AMA coding books does not indicate the endorsement of a particular brand by Practice Management Institute

Roles and Responsibilities

• Differentiate between medical ethics and medical etiquette
• Learn essential ways to keep insurance and medical knowledge current
• Demonstrate the importance of accurate coding, billing and claims submission

Compliance

• Major categories of security safeguards under HIPAA and civil/criminal non-compliance penalties
• The Privacy Rule and the definition and explanation of protected health information (PHI)
• Definition of fraud and abuse and potential fines/penalties related to fraudulent claims
• Health information technology expansion: ARRA, HITECH and the creation of incentive payments
  to eligible providers

Basics of Health Insurance

• The difference between an implied and an expressed physician-patient contract
• Actions to prevent problems when given signature authorization for insurance claims
• Physician Fee Schedule - RVUs and RBRVS
• MACRA and repeal of SGR formula

Medical Documentation

• Identify the principles and steps of the documentation
• Definitions for common medical, diagnostic and legal terms
• Reasons why an insurance company may decide to perform an external audit

ICD-10-CM Diagnostic Coding

• The purpose and importance of coding diagnoses to the highest level of specificity
• Features and use of ICD-10-CM codebook for accurate code selection
• In-class diagnostic coding exercises
• Determine medical necessity by using LCDs and NCDs

Procedural Coding

• The importance and usage of modifiers in procedure coding
• Code problems from the worksheet using the CPT® manual
• The difference between CPT, HCPCS, and Category II codes
• Use of the NCCI edits to prevent denials

Claim form CMS-1500

• Minimize the number of insurance forms returned because of improper completion
• Review CMS-1500 by section
• Expedite the handling and processing of the CMS-1500 insurance claim form
• Explain the difference between clean, rejected, incomplete, and invalid claims

Electronic Data Interchange: Transactions and Security

• Transaction and code set standards to share data between clinicians and third-party payers
• The difference between carrier-direct and clearinghouse electronically transmitted claims
• How to conquer potential computer transmission problems
• The use of EDI standards improve the accuracy of information exchanged between healthcare organizations
• Streamline business processes by using EDI standards as an eligibility and claims processing gateway

Receiving Payments and Insurance Problem-Solving

• Objectives of state insurance commissioners/state medical societies
• Communicate problems with insurance commissioners/state medical societies
• Working with denials and rejects; how to appeal for correct reimbursement
• Levels of review and redetermination in the Medicare program
• Sample letters of appeals for claims

Office and Insurance Collection Strategies

• Guidance on state prompt pay laws and the use of financial reports for more effective collections
• Patient credit options and the best practices for self-pay accounts
• Working with a billing service, collection agency, and credit bureau in the collection process
• The effects of the Affordable Care Act provisions on collections

Managed Care Plans

• Explanation of the types of managed care plans
• Types of authorizations for medical services, tests, and procedures
• Patient access to care via Accountable Care Organizations and Patient-Centered Medical Homes
• Special issues when patients are insured through the Health Insurance Exchanges

Medicare

• Utilize the lifetime beneficiary claim authorization and information release document
• How to submit claims for Medicare beneficiaries with supplemental insurance
• Proper execution of an Advance Beneficiary Notice (ABN)
• Medicare as a secondary payer rules

Medicaid and other State Programs

• Medicaid managed care system guidelines, terminology, abbreviations, eligibility classifications, benefits and non-benefits
• Medicaid claims filing for patients who have other coverage
• Minimize Medicaid rejections due to improper form completion

Workers' Compensation

• Workers' compensation insurance vs. employer's liability insurance
• Types of compensation benefits for non-disability, temporary, and permanent disability claims
• Follow-up actions for delinquent worker's comp claims
• Disability Income Insurance and Disability Benefit Programs
• Explanation and eligibility requirements for disability benefit programs and insurance plans
• Terminology and abbreviations for disability insurance and benefit programs
• How to determine whether the disability is considered temporary or permanent
• State eligibility requirements, benefits, and limitations of SSDI and SSI

“I just wanted to share with you all the positive outcomes of our employees since we started this program. Our employee morale has increased. Our employees feel more confident in answering questions from the patients. There is a sense of pride in their work and work ethics. They all have placed their certificates up in their working areas. There has been appreciation in the quality of education they each have been receiving. We have enjoyed the program and look forward to future training with you all. On behalf of HQ Chiropractic, we want to thank you all for the time invested to better educate our employees.”  

 - Betty Quiroz, HQ Chiropractic, Odessa TX

"So glad we have had the opportunity to connect with PMI again.  It has been a pleasure working with you and the whole team at PMI.  Your team makes it so easy for us to offer quality seminars at St. Vincent Evansville.  We are looking forward to continuing the relationship with PMI.”  

- Julie Morrow, Physician Liaison | Strategy

"Washington County Community College (WCCC) is delighted to be working with PMI to prepare learners for exciting career opportunities in the medical field while working to meet workforce challenges here in Maine. This exciting partnership with PMI allows us to offer relevant and rigorous coursework taught by national leading experts, specifically in the field of Medical Coding and Billing. PMI shares many of the same fundamental educational beliefs and practices around a commitment to learner success, individualized learning assistance, and high standards of course content. Because of this, we are looking forward to expanded partnership around professional development and re-certification courses."  

- Nichole Sawyer, Dean of Workforce and Professional Development, Washington County Community College