This course covers 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 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.
- 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.
- Participate in selection and development of applications and processes for chargemaster and claims management
General Education Outcomes (GEOs)
Course Activities and Grading
Discussion (Weeks 1-7)
Homework (Weeks 1-7)
Quizzes (Weeks 2, 4, 6 & 7)
Final Exam (Week 8)
Required TextbooksAvailable through https://bookstore.mbsdirect.net/vbm/vb_home.php?FVCUSNO=35478
Castro, Anne and Elizabeth Layman. Principles of Healthcare Reimbursement. 6th ed. AHIMA Press, 2018. ISBN-13: 978-1-58426-646-4
(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 Methodologies, Clinical Coding and Coding Compliance
Topic: Commerical Healthcare Insurance Plans
Topic: Government-sponsored Healthcare Programs
Topic: Managed Care Plans
Topic: Medicare-Medicaid Prospective Payment Systems for Inpatients
Topics: Ambulatory and Other Medicare-Medicad Reimbursement Systems
Topics: Revenue Cycle Management and Quality Issues
Topics: Value-Based Purchasing and Final Exam
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.