I. General Information

1. Course Title:
Medical Insurance & Billing

2. Course Prefix & Number:
HINS 1152

3. Course Credits and Contact Hours:

Credits: 2

Lecture Hours: 2

4. Course Description:

This course focuses on the medical insurance processes and the complete healthcare revenue cycle. Students learn how insurance rules, payer guidelines, and government regulations influence billing, reimbursement, and compliance. Using practice management software, students gain hands-on experience entering patient information, verifying eligibility, preparing and transmitting electronic claims, and processing payments and appeals. Students will learn to review remittance advice, reconcile patient accounts, and manage collections. Emphasis is placed on accurate documentation, compliant billing, and effective communication with payers and patients to ensure timely, clean claim submission and prompt reimbursement.

5. Placement Tests Required:

Accuplacer (specify test):

No placement tests required

Score:

6. Prerequisite Courses:

There are no prerequisites for this course.

7. Other Prerequisites
HINS 1163 Medical Office Procedures

9. Co-requisite Courses:

There are no corequisites for this course.

II. Transfer and Articulation

1. Course Equivalency - similar course from other regional institutions:

Century College, Medical Office Insurance and Billing  3 credits

Minnesota West - Pipestone Campus, Reimbursement and Insurance in Healthcare   2 credits

2. Transfer - regional institutions with which this course has a written articulation agreement:

College of St. Scholastica, Articulation agreement signed Summer 2020 (General Elective)

MSU - Moorhead, Articulation agreement signed Spring 2019 (MSU-M Electives)

III. Course Purpose

1. Program-Applicable Courses – This course fulfills a requirement for the following program(s):

Medical Coding & Billing Diploma

Medical Practice Managment A.A.S.

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Analyze and follow a sequence of operations	Describe and apply the process for calculating reimbursement, compliant billing, and preparing and transmitting claims.
Utilize appropriate technology	Use practice management software to enter patient information, generate insurance claims, post payments, appeal denials, and reconcile patients accounts accurately and efficiently.

2. Course Specific Outcomes - Students will be able to achieve the following measurable goals upon completion of the course:

• Differentiate among major types of medical insurance, payers, and regulatory agencies and explain their impact on billing and reimbursement;
• Apply reimbursement methodologies to calculate payments and interpret remittance advice for accuracy and compliance;
• Use practice management software to prepare, submit, and track electronic healthcare claims;
• Follow payer-specific guidelines for third-party and government-sponsored insurance programs to ensure compliant and timely claim submission;
• Process and post payments, identify denials, and complete claim follow-up or appeals using appropriate documentation; and
• Generate and reconcile patient statements and apply ethical and legal standards in billing and collection procedures.

V. Topical Outline

Listed below are major areas of content typically covered in this course.

1. Lecture Sessions

1. Revenue Cycle
• Healthcare Insurance Plans
• Health Maintenance Organizations
• Preferred Provider Organizations
• Consumer-Driven Health Plans
• Medical Insurance Payers
• Revenue Cycle
2. HIPAA and HITECH
• Healthcare Regulations
• Covered Entities and Business Associates
• Omnibus Rule and Enforcement
• Fraud and Abuse Regulations
• Compliance Plans
3. Patient Encounters and Billing Information
• New Versus Established Patient
• Patient Eligibility for Insurance Benefits
• Preauthorization and Referral
• Primary, Secondary, and Tertiary Insurance
• Encounter Forms
4. Charges and Compliant Billing
• Billing Rules
• Compliance Strategy
• Audits
• Physician Fees
• Payer Fee Schedule
• Fee-based Payment
• Capitation
5. Claims
• Claim Preparation and Transmission
• CMS-1500 Forms
• Clearinghouses
6. Insurance Plans
• Private Payers
• Group Health Plans
• Consumer-Driven Health Plans
• BlueCross BlueShield Association
• Affordable Care Act (ACA) Plans
• Participation Contracts
• Compensation and Billing Guidelines
• Medicare
• Eligibility Requirements
• Coverage and Benefits
• Participating Provider
• Nonparticipating Provider
• Advantage Plans
• Additional Coverage Options
• Billing and Compliance
• Medicaid
• Eligibility Requirements
• State Programs
• Enrollment Verification
• Covered and Excluded Services
• Plans and Payments
• Third-party Liability
• TRICARE and CHAMPVA
• Provider Participation and Nonparticipation
• TRICARE Plan
• TRICARE and Other Insurance Plans
• CHAMPVA
• Workers' Compensation and Disability/Auto Insurance
• Federal Workers' Compensation Plans
• State Workers' Compensation Plans
• Claim Process
• Disability Compensation and Automotive Insurance Programs
7. Claim Follow-up and Payment Processing
• Payments, Appeals, and Secondary Claims
• Claim Adjudication
• Remittance Advice (RA)
• Post Payments
• Appeals
• Refunds
• Secondary Payer Billing
• Patient Billing and Collections
• Patient Financial Responsibility
• Patient Statements
• Collection Process
8. Hospital Services
• Billing and Reimbursement
• Inpatient versus Outpatient
• Payers and Payments
• Claims and Follow-up