HIM 63 - Reimbursement

Transfer Status

CSU

Unit(s)

3.00

• Lecture: 51.00 Contact hours/102.00 Out of class hours/153.00 Total hours/3.00 Unit(s)
• Total: 51.00 Contact hours/102.00 Out of class hours/153.00 Total hours/3.00 Unit(s)

Course Description: This course introduces students to the reimbursement methodologies used in healthcare in the United States. The focus of the course will be on the accurate preparation and maintenance of clinical records and medical documentation. Students will analyze insurance plans spanning government and private sectors and learn to properly complete the Centers for Medicare and Medicaid Services claim form (CMS 1500) used in medical outpatient facilities. Topics include working with specific insurance companies, filing error-free claims, resubmitting denied claims, utilizing effective collection strategies, and handling the appeal process.

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

1. Analyze Compliance Alerts and Health Insurance Portability and Accountability (HIPAA) regulations in relation to proper medical insurance reimbursement techniques.
2. Explain the importance of clinical records and medical documentation for creating claims.
3. Compare and contrast the various health insurance plans and their requirements for medical reimbursement.
4. Create and complete error-free claim reimbursement insurance forms (CMS 1500) utilizing proper diagnostic and procedural codes.
5. Explain the techniques of handling collections.

Topic Titles / Suggested Time Topic

Lecture

1. Class Activities
2. Discussion
3. Homework: Students are required to complete two hours of outside-of-class homework for each hour of lecture
4. Lecture

1. Exams/Tests
2. Projects
3. Performance Examinations
4. Short papers

Reading Assignments

1. Read the article on "Clinical Records and Medical Documentation" and be prepared to discuss the importance of the 15 rules of medical documentation with your class.
2. Read the article on "Ethical and Legal Issues of Medical Reimbursement." Define ethics and outline the ethical standards set by the American Medical Association that providers should follow. Be prepared to share your findings with your class.

Writing Assignments

1. In a one-page paper, describe the responsibilities in handling reimbursements and creating reports for a medical billing system.
2. In a one-page paper, complete the following statement and provide additional information to justify your answer: "If you needed to verify a diagnosis, affected body area, or spelling of terms and definitions, you would probably refer to the . . . ."

Out-of-Class Assignments

1. Given a client's insurance contract and medical documentation indicating diagnosis and treatment, complete a clean CMS-1500 Claim Form Matrix.
2. Create a spreadsheet identifying the features for each of the medical insurance plans--Medicare/Medicaid, Worker's Compensation, Health Maintenance Organizations, and Preferred Provider Organizations. Be prepared to share your spreadsheet with your class.

Fordney, Marilyn. (2016). Insurance Handbook For Medical Office. Saunders, 15th.

Fordney, Marilyn. (2016). Insurance Handbook for Medical Office, Student Workbook. Saunders, 15th.

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