I. General Information

1. Course Title:
Reimbursement Methodology

2. Course Prefix & Number:
HINS 2172

3. Course Credits and Contact Hours:

Credits: 3

Lecture Hours: 3

4. Course Description:

This course provides training as it relates to medical billing and health insurance. Topics covered will be statement preparation in the medical office, types of medical insurance companies, types of coverage, the claim process from beginning to end (includes generating the claim, using a clearing house, and getting reimbursed), and related ethical and legal issues. Topics such as rejection of claims and filing appeals will be discussed.

5. Placement Tests Required:

6. Prerequisite Courses:

9. Co-requisite Courses:

There are no corequisites for this course.

II. Transfer and Articulation

III. Course Purpose

1. Program-Applicable Courses – This course is required for the following program(s):

Healthcare Administrative Specialist, AAS Degree
Healthcare Administrative Specialist, Diploma
Healthcare Accounting, AAS Degree

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Analyze and follow a sequence of operations	Obtain correct reimbursement using federal and state guidelines.
Apply abstract ideas to concrete situations	Apply claims appeal processes to solve denied claims for proper reimbursement.
Apply ethical principles in decision-making	Comply with federal and state laws while working with payer regulations.

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

• Define RVU and DRG;
• Explain the different codes sets approved by the HIPAA Act of 1996;
• Define basic language associated with reimbursement under Medicare and Medicaid healthcare payment systems;
• Explain common models and policies of payment for Medicare and Medicaid healthcare payment system for physicians in an outpatient setting;
• Describe models of pay-for-performance;
• Describe the components of the revenue cycle and the importance of effective revenue cycle management for fiscal stability; and
• Describe types of managed care plans.

V. Topical Outline

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

1. Lecture Sessions

1. Healthcare reimbursement methodologies
• Types of healthcare reimbursement methods
• Fee-for-service reimbursement
• Episode-of-care reimbursement
2. Trends in reimbursement
• Dominance of federal healthcare payment methods
• Constantly increasing healthcare spending
• Healthcare reform
• Use of health information and communication technologies
3. Clinical coding and coding compliance
• Clinical coding-reimbursement connection
• The international classification of diseases
• Healthcare common procedure coding system
• Coding systems as communication facilitators
4. Coding compliance and reimbursement
• Fraud and abuse
• Oversight of Medicare claims payments
• Third-party payer reviews
• Coding compliance plan
5. Voluntary healthcare insurance plans
• Voluntary healthcare insurance
• Types of voluntary healthcare insurance
• Terminology
• Private (individual) healthcare plans
• Employer-based (group) healthcare plans
• BCBS plans
• State healthcare plans for the medically uninsured
6. Provisions and functioning of healthcare insurance plans
7. Section of a healthcare insurance policy
• Definitions
• Eligibility and enrollment
• Benefits
• Limitations
• Exclusions
• Riders and endorsements
• Procedures
• Appeals process
8. Determination of covered services
9. Elements of healthcare insurance identification card
10. Filing a healthcare insurance claim
11. Remittance advice or explanation of benefits
12. Trends
• Implementation of Affordable Care Act
• Increasing costs in voluntary healthcare insurance
13. Government sponsored healthcare programs
• Medicare
• Medicare Part A for inpatients
• Medicare Part B
• Medicare Part C
• Medicare Part D
• Medigap
14. Medicare market basket updates: reductions and productivity adjustments
15. Medicaid
16. Other government sponsored healthcare programs
• Temporary assistance for needy families program
• Programs for all-inclusive care for the elderly
• Children’s health insurance program
• TRICARE
• CHAMPVA
• The Indian Health Service
• Workers’ compensation
17. Managed care plans
• Managed care organizations (MCO)
• Benefits and services of MCOs
• Characteristics of MCOs
• Types of MCOs
18. Integrated delivery systems
• Integrated provider organization
• Group practice without walls
• Physician-hospital organization
• Management service organization
• Medical foundation
19. Trends
• Access of vulnerable populations to health services
• Utilization
20. Medicare-Medicaid prospective payment systems for inpatients
• Acute-care prospective payment system
• Conversion from cost-based payment to prospective payment
• Diagnosis-related group classification
21. Inpatient psychiatric facility prospective payment system
• Patient-level adjustments
• Facility-level adjustments
• Provisions of the inpatient psychiatric facility prospective payment system
• Payment steps
22. Ambulatory and other Medicare-Medicaid reimbursement systems
• Reimbursement systems for physicians and ambulatory settings
• Resource-based relative value scale for physicians and professional payments
• Structure of payment
• Calculation
• Potential adjustments
• Operational issues
23. Ambulance fee schedule
• Development of the ambulance fee schedule
• Implementation of the ambulance fee schedule
• Reimbursement for ambulance services
• Office of Inspector General report
• Recent adjustments to the system
• Expiration of transition period – future updates
24. Hospital outpatient prospective payment system
• Legislative influence
• Hospital outpatient prospective payment methodology
• Ambulatory payment classification system
• Payment determination
25. Ambulatory surgical center prospective payment system
• Medicare certification standards
• Payment for ambulatory surgical center services
• Criteria for ambulatory surgical center procedures
• Ambulatory payment classifications and payment rates
• Separately payable services
• Device-intensive procedures
• Multiple and bilateral procedures
• Interrupted procedures
• Transition period
• Payment steps
26. End-stage renal disease prospective payment system
• Renal dialysis services
• Self-dialysis training
• Transition period
27. Payment for safety-net providers
• Medicare cost sharing
• Characteristics of federally qualified health centers and rural health clinics
• Reimbursement
28. Hospice service payment system
• Reimbursement
• Implementation
29. Medicare-Medicaid prospective payment systems for post-acute care
• Skilled nursing facility prospective payment system
• Data collection and reporting
• Structure of payment
• Payment
30. Long-term care hospital prospective payment system
• Structure of payment
• Payments and potential adjustments
• Implementation
31. Inpatient rehabilitation facility prospective payment system
• Data collection and reporting
• Structure of payment
• Payment and potential adjustments
• Implementation
32. Home health prospective payment system
• Data collection and reporting
• Structure of payment
• Payment and potential adjustments
• Implementation
33. Revenue cycle management
• Multidisciplinary approach
• Components of the revenue cycle
• Preclaims submission activities
• Claims processing activities
• Accounts receivable
• Claims reconciliation and collection
34. Revenue cycle management (RCM) team
• RCM case study
• RCM trends
35. Value-based purchasing
• Introduction to value-based purchasing and pay-for-performance systems
• Definitions
• Purpose
• Advantages and disadvantages
• Models
• Operations
36. Centers for Medicare and Medicaid services – linking quality to reimbursement
• Value-based purchasing
• Pay-for-reporting
• Pay-for-performance
• Paying for value
• The future of value-based purchasing