HIM 205: Reimbursement Methodologies

Course Description

This course covers the types of healthcare insurance and reimbursement methodologies used in all healthcare settings as they relate to national billing, compliance, and reporting requirements. Topics include prospective payment systems, billing process and procedures, chargemaster maintenance, regulatory guidelines, reimbursement monitoring, and compliance strategies and reporting. Upon completion, students should be able to describe the health insurance claims process, explain the steps for completing a claim form, and comply with reimbursement and reporting requirements.  (3 credits)

This course meets certain CAHIIM competencies for HIM Majors.

Prerequisite

  • ENG 101: English Composition 1

Student Learning Outcomes (SLOs)

Upon successful completion of the course, the student will be able to:

  1. Distinguish major payment methods in the US.
  2. Discuss the coding compliance issues that influence reimbursement.
  3. Differentiate major types of healthcare insurance plans.
  4. Define basic language associated with reimbursement by commercial healthcare insurance plans and by Blue Cross and Blue Shield plans.
  5. Differentiate among and identify the various government-sponsored healthcare programs.
  6. Discuss the history of the Medicare and Medicaid programs in America.
  7. Describe and trace the origins and evolution of the different types of managed care plans.
  8. Manage the use of clinical data required by various payment and reimbursement systems.
  9. Define and discuss the components of the revenue cycle management.
  10. Apply principles of healthcare finance for revenue management
  11. Implement processes for revenue cycle management and reporting
  12. Describe the origins and evolution of value-based purchasing and pay for performance models.
  13. Describe the steps in the healthcare claims process and the steps in completing the universal forms used.

Course Activities and Grading

Note: A "C" grade or higher must be earned to pass this course.

Letter GradePercentage
A93.0-100.0 
A -90.0-92.9 
B+87.0-89.9 
B83.0-86.9 
B -80.0-82.9 
C +77.0-79.9 
C73.0-76.9 
F72.99% and below



AssignmentsWeight

Discussion (Weeks 1-7)

20%

EHR Go Labs and Assignments

20%

Quizzes

40%

Final Exam (Week 8)

 20%

Total

100%

Required Textbooks

Available through Charter Oak State College's Book Bundle

  • Castro, Anne and Elizabeth Layman. Principles of Healthcare Reimbursement - with Access Code. 7th ed. AHIMA Press, 2021. ISBN-13: 978-1-58426-800-0

  • EHR Go Lab Access. Archetype Innovations. Students can choose length of subscription (12 weeks to 1 year – it will be used in some other courses).  This can also be purchased directly from EHR Go for a less expensive option.

Course Schedule

Notes: Course week runs Monday 12:00 am EST - Sunday 11:59 pm EST. Initial Discussion Posts are due by end of day Wednesday.  All other work is due by end of day Sunday:

Week

SLOs

Readings and Exercises

Assignments

1

1,3

Topics: Healthcare Reimbursement and Revenue Cycle Management

  • Reading:
    • Chapters 1 & 4
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Submit Chapter 1 Quizzes
  • Register for EHR Go

2

4,5

Topic: Health Insurance

  • Reading:
    • Chapter 2
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Assignment: EHR Go New Patient Registration
  • Complete Chapter 2 Quizzes

3

6,7

Topic: Government Sponsored Healthcare Programs

  • Reading:
    • Chapter 3
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Assignment:  EHR Go – Medicare Insurance Card Review
  • Submit Chapter 3 Quizzes

4

2

Topics: Healthcare Reimbursement Methodologies; Medicare Hospital Acute Inpatient Payment System

  • Reading:
    • Chapters 4 and 5
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Complete Chapter 4 and 5 Quizzes

5

1,7,12

Topics: Medicare Skilled Nursing Facility Services Payment System; Medicare Hospital Outpatient Payment System; Medicare Physician and Other Health Professional Payment System

  • Reading:
    • Chapters 6, 7 and 8
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Submit Chapter 6, 7, and 8 Quizzes

6

1,7,12

Topics: Revenue Cycle Front-End Processes – Patient Engagement, Revenue Cycle Middle Processes – Resource Tracking

  • Reading:
    • Chapters 9 & 10
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Assignment -  EHR Go lab: Creating a Claim
  • Complete Week 6  Chapters 9 and 10 Quizzes

7

8,9,10,11,13

Topics: Revenue Cycle Back-End Processes – Claims Production and Revenue Collection; Coding and Clinical Documentation Integrity Management

  • Reading:
    • Chapters 11 and 12
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • Assignment – EHR Go lab: Posting Payments and Adjustments
  • Complete Chapter 11 and 12 Quiz)
  • Submit Assignment – Back End Revenue Cycle Processes

8

1-13

Topics: Revenue Compliance; Revenue Cycle Analysis

  • Reading:
    • Chapters 13 and 14
  • Read assigned chapters
  • Participate in the discussions
  • Review the lecture material
  • EHR Go Lab: CMS 1500
  • Complete Chapters 13 and 14 Open Book Quiz
  • Complete Course Evaluation

Final Exam
Chapters 1-14
SLOs 1-13

COSC Accessibility Statement

Charter Oak State College encourages students with disabilities, including non-visible disabilities such as chronic diseases, learning disabilities, head injury, attention deficit/hyperactive disorder, or psychiatric disabilities, to discuss appropriate accommodations with the Office of Accessibility Services at OAS@charteroak.edu.

COSC Policies, Course Policies, Academic Support Services and Resources

Students are responsible for knowing all Charter Oak State College (COSC) institutional policies, course-specific policies, procedures, and available academic support services and resources. Please see COSC Policies for COSC institutional policies, and see also specific policies related to this course. See COSC Resources for information regarding available academic support services and resources.