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.
- ENG 101: English Composition 1
Student Learning Outcomes (SLOs)
Upon successful completion of the course, the student will be able to:
- Distinguish major payment methods in the US.
- Discuss the coding compliance issues that influence reimbursement.
- Differentiate major types of healthcare insurance plans.
- Define basic language associated with reimbursement by commercial healthcare insurance plans and by Blue Cross and Blue Shield plans.
- Differentiate among and identify the various government-sponsored healthcare programs.
- Discuss the history of the Medicare and Medicaid programs in America.
- Describe and trace the origins and evolution of the different types of managed care plans.
- Manage the use of clinical data required by various payment and reimbursement systems.
- Define and discuss the components of the revenue cycle management.
- Apply principles of healthcare finance for revenue management
- Implement processes for revenue cycle management and reporting
- Describe the origins and evolution of value-based purchasing and pay for performance models.
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.
|F||72.99% and below|
Discussion (Weeks 1-7)
EHR Go Labs and Assignments
Final Exam (Week 8)
Available through Charter Oak State College's online bookstore
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.
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:
Readings and Exercises
Topics: Healthcare Reimbursement and Revenue Cycle Management
Topic: Health Insurance
Topic: Government Sponsored Healthcare Programs
Topics: Healthcare Reimbursement Methodologies; Medicare Hospital Acute Inpatient Payment System
Topics: Medicare Skilled Nursing Facility Services Payment System; Medicare Hospital Outpatient Payment System; Medicare Physician and Other Health Professional Payment System
Topics: Revenue Cycle Front-End Processes – Patient Engagement, Revenue Cycle Middle Processes – Resource Tracking
Topics: Revenue Cycle Back-End Processes – Claims Production and Revenue Collection; Coding and Clinical Documentation Integrity Management
Topics: Revenue Compliance; Revenue Cycle Analysis
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.