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 revenue cycle and how the rules and guidelines of medical insurance affect patient billing and the healthcare facilities bottom line. The course will cover the importance of medical practice in billing both patients and payers, how to manage both patient records and the billing/collections process, and the importance of clean claim submissions. Emphasis will be placed on applying the rules of Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) to ensure compliance, maximum reimbursement, and the electronic exchange of health information.

5. Placement Tests Required:

Accuplacer (specify test):

No placement tests required

Score:

6. Prerequisite Courses:

There are no prerequisites for this course.

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

III. Course Purpose

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

Healthcare Administrative Specialist, AAS
Healthcare Administrative Specialist, Diploma

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Analyze and follow a sequence of operations	Describe the procedures for calculating reimbursement, how to bill compliantly, and preparing and transmitting claims.
Apply ethical principles in decision-making	Explain the importance of applying HIPAA/HITECH Privacy, Security, and Electronic Healthcare Transactions, Code Sets, and Breach Notification rules to medical billing.

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

• Explain the major types of medical insurance, payers, and regulators;
• Describe the process for calculating reimbursement;
• Explain the steps in preparing and transmitting claims;
• Describe the major third-party and government sponsored payers' procedures and regulations along with specific filing guidelines;
• Explain the application of payments from payers, follow-up and appeal claims; and
• Explain process to correctly bill and collect from patients.

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