I. General Information

1. Course Title:
Reimbursement Methodology

2. Course Prefix & Number:
HINS 2172

3. Course Credits and Contact Hours:

Credits: 2

Lecture Hours: 2

4. Course Description:

This course provides additional training as it relates to medical billing and health insurance reimbursement. The course provides the step-by-step details of how each payment system functions. Topics covered in this course include assessing and using fee schedules, payment classification groups, exclusion lists, market baskets, and wage indexes required for accurate reimbursement. The course will also look at the various methods, plans, and programs of government-sponsored payment systems, commercial insurance, and managed care.

5. Placement Tests Required:

Accuplacer (specify test):

No placement tests required

Score:

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 Accounting, AAS Degree

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Apply abstract ideas to concrete situations	Explain the common models and policies of payment for inpatient prospective payment systems versus payment systems for physicians and outpatient settings.
Apply ethical principles in decision-making	Using the Centers for Medicare and Medicaid regulations define the grouping models and payment formula associated with reimbursement.

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

• Explain the basic concept of healthcare reimbursement in step-by-step, simple terms;
• Describe the differences between the various government-sponsored healthcare programs and explain their effect on the American healthcare system;
• Explain common models and policies of payment for inpatient Medicare and Medicaid prospective payment systems;
• Explain common models and policies of payment for Medicare and Medicaid healthcare payment systems for physicians and outpatient settings;
• Describe the federal payment systems for the settings that provide care for patients recovering from inpatient acute care and the Centers for Medicare and Medicaid (CMS) quality initiatives for the hospital inpatient and outpatient settings; and
• Describe the connection between effective revenue cycle management and providers' fiscal stability.

V. Topical Outline

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

1. Lecture Sessions

1. Review 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. Medicare market basket updates: reductions and productivity adjustments
4. Medicare-Medicaid prospective payment systems for inpatients
• Acute-care prospective payment system
• Conversion from cost-based payment to prospective payment
• Diagnosis-related group classification
5. Inpatient psychiatric facility prospective payment system
• Patient-level adjustments
• Facility-level adjustments
• Provisions of the inpatient psychiatric facility prospective payment system
• Payment steps
6. 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
7. 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
8. Hospital outpatient prospective payment system
• Legislative influence
• Hospital outpatient prospective payment methodology
• Ambulatory payment classification system
• Payment determination
9. 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
10. End-stage renal disease prospective payment system
• Renal dialysis services
• Self-dialysis training
• Transition period
11. Payment for safety-net providers
• Medicare cost sharing
• Characteristics of federally qualified health centers and rural health clinics
• Reimbursement
12. Hospice service payment system
• Reimbursement
• Implementation
13. Medicare-Medicaid prospective payment systems for post-acute care
• Skilled nursing facility prospective payment system
• Data collection and reporting
• Structure of payment
• Payment
14. Long-term care hospital prospective payment system
• Structure of payment
• Payments and potential adjustments
• Implementation
15. Inpatient rehabilitation facility prospective payment system
• Data collection and reporting
• Structure of payment
• Payment and potential adjustments
• Implementation
16. Home health prospective payment system
• Data collection and reporting
• Structure of payment
• Payment and potential adjustments
• Implementation
17. Revenue cycle management
• Multidisciplinary approach
• Components of the revenue cycle
• Pre-claims submission activities
• Claims processing activities
• Accounts receivable
• Claims reconciliation and collection
18. Revenue cycle management (RCM) team
• RCM case study
• RCM trends
19. Value-based purchasing
• Introduction to value-based purchasing and pay-for-performance systems
• Definitions
• Purpose
• Advantages and disadvantages
• Models
• Operations
20. 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
21. Reimbursement Trends
• Implementation of Affordable Care Act
• Increasing Costs in Voluntary Healthcare Insurance