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HIM 205: Reimbursement Methodologies

Course Description

This course will focus on 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, charge master maintenance, regulatory guidelines, reimbursement monitoring, and compliance strategies and reporting. Upon completion, students should be able to perform data quality reviews to validate code assignment 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. Participate in selection and development of applications and processes for chargemaster and claims management

General Education Outcomes (GEOs)

Please check the applicable GEOs for this course, if any, by outcomes at GEO Category Search, or by subject area at GEO Discipline Search.

Course Activities and Grading

Assignments

Weight

Discussion (Weeks 1-7)

20%

Homework (Weeks 1-7)

20%

Quizzes (Weeks 2, 4, 6 & 7)

40%

Final Exam (Week 8)

 20%

Total

100%

Required Textbooks

Available through https://bookstore.mbsdirect.net/vbm/vb_home.php?FVCUSNO=35478
  • Castro, Anne and Elizabeth Layman. Principles of Healthcare Reimbursement. 5th ed. AHIMA Press, 2015. ISBN-13: 9781584264347

Course Schedule

(Note: Course week runs Monday 12:00 am EST - Sunday 11:59 pm EST)

Week

SLOs

Readings and Exercises

Assignment(s)

1

1,2,3

Topics: Healthcare Reimbursement Methodologies, Clinical Coding and Coding Compliance

  • Reading:
    • Chapters 1 & 2
  • Read assigned chapters
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Submit Competency Assignment - Coding Audit Analysis (Student Online Workbook) (Due by Sunday 11:59 pm EST)
  • Submit Chapter 1 & 2 Review Quiz (Due by Sunday 11:59 pm EST)

2

4,5

Topic: Voluntary Healthcare Insurance Plans

  • Reading:
    • Chapter 3
  • Read assigned chapter
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Complete Quiz 1 (Chapters 1 and 2) (Due by Sunday 11:59 pm EST)
  • Submit Chapter 3 Review Quiz (Due by Sunday 11:59 pm EST)

3

6,7

Topic: Government-sponsored Healthcare Programs

  • Reading:
    • Chapter 4
  • Read assigned chapter
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Submit Chapter 4 Review Quiz (Due by Sunday 11:59 pm EST)

4

8

Topic: Managed Care Plans

  • Reading:
    • Chapter 5
  • Read assigned chapter
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Complete Quiz 2 (Chapters 3 and 4) (Due by Sunday 11:59 pm EST)
  • Submit Chapter 5 Review Quiz (Due by Sunday 11:59 pm EST)

5

1,7

Topic: Medicare-Medicaid Prospective Payment Systems for Inpatients

  • Reading:
    • Chapter 6
  • Read assigned chapter
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Submit Chapter 6 Review Quiz (Due by Sunday 11:59 pm EST)

6

1,7

Topics: Ambulatory and Other Medicare-Medicad Reimbursement Systems

  • Reading:
    • Chapter 7
  • Read assigned chapter
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Complete Quiz 3 (Chapters 5 and 6) (Due by Sunday 11:59 pm EST)
  • Submit Chapter 7 Review Quiz (Due by Sunday 11:59 pm EST)

7

9,10

Topics: Revenue Cycle Management and Quality Issues

  • Reading:
    • Chapters 8 & 9
  • Read assigned chapters
  • Participate in the Discussions (Postings must be completed on three separate days throughout the week by Sunday 11:59 pm EST)
  • Review the Lecture material
  • Submit Competency Assignment - Chargemaster Management (Student online workbook) (Due by Sunday 11:59 pm EST)
  • Complete Quiz 4 (Chapters 7, 8 and 9) (Due by Sunday 11:59 pm EST)
  • Prepare for the Week 8 Final Exam

8

1-10

Topics: Value-Based Purchasing and Final Exam

  • Reading:
    • Chapter 10
  • Submit Chapter 10 Review Quiz (Due by Saturday 11:59 pm EST)
  • Complete Final Exam (Due by Saturday 11:59 pm EST)
  • Complete Course Evaluation

Final Exam
Chapters 1-10
SLOs 1-10

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.