May 21, 2022  
2020-2021 Course Catalog 
    
2020-2021 Course Catalog [ARCHIVED CATALOG]

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HIT 290 - Reimbursement Methods

Credits: 3
Lecture Hours: 2
Lab Hours: 2
Practicum Hours: 0
Work Experience: 0
Course Type: Voc/Tech
This introduction to health insurance and reimbursement studies payment systems for all types of healthcare systems and managed care. Changing trends in the reimbursement of healthcare services are reviewed. Topics include prospective payment systems, charge master maintenance, DRGs, APCs, ASC Groups, RBRVs, third-party payers, EOB, Quality Improvement Organizations, managed care/capitation and compliance. Students practice completing claim forms for a variety of medical scenarios and learn the importance of accurate coding and medical necessity to ensure proper reimbursement.
Competencies
  1. Evaluate healthcare reimbursement methodologies.
    1. Differentiate common national models of healthcare delivery.
    2. Describe the characteristics of the US healthcare delivery sector.
    3. Explain the influence of the federal government in the US healthcare sector.
    4. Summarize the history of development of health insurance in US.
    5. Differentiate payment methods on unit of payment, time frame, and risk.
    6. Summarize types of healthcare reimbursement methodologies.
    7. Compare and contrast fee-for-service reimbursement from episode-of-care reimbursement.
    8. Describe trends in the healthcare sector.
    9. Define terms associated with healthcare reimbursement methodologies.
  2. Examine clinical coding and coding compliance.
    1. Differentiate the difference code sets approved by the healthcare Insurance Portability and Accountability Act of 1996.
    2. Describe the structure of approved code sets.
    3. Examine coding compliance issues that influence reimbursement.
    4. Explain the roles of various Medicare improper payment review entities.
  3. Characterize voluntary healthcare insurance plans
    1. Discuss major types of voluntary healthcare insurance plans.
    2. Differentiate individual healthcare plans from employer-based healthcare plans.
    3. Review types of Blue Cross and Blue Shield plans and state healthcare plans for the medically uninsurable that are available.
    4. Explain the provisions of healthcare insurance policies and the elements of a healthcare insurance identification card.
    5. Review the filing process of a healthcare insurance claim.
    6. Discuss remittance advices and explanations of benefits.
    7. Define basic language associated with reimbursement by commercial healthcare insurance plans and by Blue Cross and Blue Shield plans.
  4. Distinguish the different government-sponsored healthcare programs.
    1. Differentiate among and to identify the various government-sponsored healthcare programs.
    2. Summarize the history of the Medicare and Medicaid programs in America.
    3. Review the effect that government-sponsored healthcare programs have on the American healthcare system.
  5. Outline managed care plans.
    1. Define and trace the origins of managed care.
    2. Delineate characteristics of managed care in terms of quality and cost-effectiveness.
    3. Describe common care management tools used in managed care.
    4. Discuss accreditation processes and performance improvement initiatives used in managed care.
    5. Define cost controls used in managed care.
    6. Summarize contract management and carve-outs.
    7. Define types of managed care plans along a continuum of control.
    8. Describe the use of managed care in states? Medicaid programs, Children?s Health Insurance Program, and Medicare.
    9. Discuss types of integrated delivery systems.
    10. Define terms commonly used in managed care.
  6. Examine Medicare-Medicaid prospective payment systems for inpatients
    1. Differentiate major types of Medicare and Medicaid prospective payment systems for inpatients.
    2. Define basic language associated with reimbursement under Medicare and Medicaid prospective payment systems.
    3. Explain common models and policies of payment for inpatient Medicare and Medicaid prospective payment systems.
    4. Describe the elements of the inpatient prospective payment system.
    5. Examine the elements of the inpatient psychiatric prospective payment system.
    6. Differentiate critical access hospital reimbursement with other prospective payment systems
  7. Distinguish ambulatory and other Medicare-Medicaid reimbursement systems
    1. Differentiate major types of Medicare and Medicaid reimbursement systems for beneficiaries.
    2. Define basic language associated with reimbursement under Medicare and Medicaid healthcare payment systems.
    3. Explain common models and policies of payment for Medicare and Medicaid healthcare payment systems for physicians and outpatient settings.
    4. Identify the elements of the relative value unit and major components for the resource-based relative value scale payment system.
    5. Describe the elements of the ambulance fee schedule and the end-stage renal disease prospective payment system.
    6. Explain the elements of the outpatient prospective payment system and the ambulatory surgical center payment system.
    7. Discuss the elements of the payment systems for federally qualified health centers and rural health clinics.
    8. Summarize the elements of the hospice services and payment systems.
  8. Differentiate Medicare-Medicaid prospective payment systems for postacute care
    1. Define the postacute care settings.
    2. Differentiate the Medicare and Medicaid prospective payment systems for healthcare services delivered to patients in postacute care.
    3. Describe Medicare’s all-inclusive per diem rate for skilled nursing facilities.
    4. Explain Medicare’s prospective payment systems for long-term care hospitals and inpatient rehabilitation facilities.
    5. Summarize Medicare’s per-episode payment system for home health agencies.
    6. Distinguish the specialized collection instruments, standardized base rates, and case-mix groups that exist in postacute care.
    7. Describe basic language associated with reimbursement under Medicare and Medicaid prospective payment systems in postacute care.
    8. Explain the grouping models and payment formulae associated with reimbursement under Medicare and Medicaid prospective payment systems in postacute care.
  9. Examine revenue cycle management
    1. Describe the components of the revenue cycle.
    2. Define the components of the structure and maintenance of the charge description master
    3. Discuss compliance guidance resources and tools available to assist with maintenance of the charge description master.
    4. Explain the purpose of how a revenue cycle management team can improve the efficiency and effectiveness of the revenue cycle process with utilizing key performance indicators and developing different methods of revenue cycle analysis.
    5. Review different methods of revenue cycle analysis such as case-mix index analysis, MS-DRG relationships reporting, outpatient code editor review, site of service review IP vs OP, E/M coding review, etc.
  10. Characterize value-based purchasing, pay for performance and accountable care organizations
    1. Describe the origins and evolution of value-based purchasing, pay-for-performance and accountable care organizations.
    2. Discuss models of value-based purchasing, pay-for-performance and accountable care organizations.
    3. Examine models of value-based purchasing and pay for reporting programs implemented by the Centers for Medicare and Medicaid Services for various healthcare settings and payment systems
    4. Explain how compliance with the Centers for Medicare and Medicaid Services value-based purchasing programs affects healthcare reimbursement for a facility, entity, or a professional.



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