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Table of Contents | Areas of Study | Health Information Technology | HITT220 syllabus

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COURSE NUMBER: HITT220
COURSE TITLE:Insurance Procedures
DIVISION:Sciences
IAI CODE(S):
SEMESTER CREDIT HOURS:3.0
DELIVERY MODE:

COURSE DESCRIPTION:
The terminology, rationale and methodology (RUG III, RVU, RBRVs, DRGs, APCs, IVCD, LMPR, ABN, EOB) used by third-party payers to determine the reimbursement for health care providers will be examined.  Proper completion of the 1500 billing form and legal issues related to reimbursement will be discussed, as well as the role HIM plays in the Charge Description Master, Reimbursement Monitoring, Revenue Cycle, Compliance and Case-Mix Management. An overview of hospital and nursing home billing systems including proper submission of UB-92 billing forms will also be covered.

PREREQUISITES:
AAS Candidates - completion of HITT125 with a grade of C or better; Certificate Candidates - completion of or current enrollment in HITT101 and HITT105.

NOTES: The expanded version of objectives is available from the HITT director.

This course is not available for web registration.

COURSE OBJECTIVES / GOALS:
By the end of the course the students will be able to do the following:
  1. Describe managed health care
  2. Compare the different types of insurance
  3. Define insurance terms
  4. Describe what is a deductible
  5. Describe the method of filing insurance claims
  6. Describe the method of processing an insurance claim
  7. Process insurance claims identifying actual charges vs. allowed charges
  8. Computing RUG III, RVU, RBRVs used by third-party payers to determine the reimbursement for health care providers will be examined
  9. Process computerized billing
  10. Identify the role of CMS in relation to insurance claims
  11. Define the legal and regulatory consideration in relation to insurance claims
  12. Describe an OIG work plan and HCCI edits
  13. Verify validity of data sources (charges, billing reports, and other data sources)
  14. Validate DRG and APC assignments based on groupers and decision trees
  15. Validate UB-92 forms and HCFA 1500 forms
  16. Perform CPT-4 and ICD-9-CM coding accurately on insurance forms
  17. Use specialized software in the completion of billing in HIM processes
  18. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, Managed care and so forth
  19. Verify completeness, accuracy, and appropriateness of data and data source for billing reports
  20. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment system (PPS) in healthcare delivery
  21. Support accurate billing through coding, Chargemaster, claims management, and bill reconciliation processes
  22. Use established guidelines to comply with reimbursement and reporting requirements (National Correct Coding Initiative)
  23. Apply policies and procedures to comply with the changing regulations among various payment system for healthcare services such as Medicare, Medicaid, and managed care
  24. Use specialized software in the completion of billing
  25. Monitor revenue cycle processes
  26. Discuss the role of HIM in the revenue cycle and development of the charge master
  27. Discuss the role of HIM in case management
  28. Discuss the role of RAC and its impact on health care facilities
  29. Discuss the required and mandatory disclosure laws and HIPAA in relation to insurance procedures
  30. Compile patient data and perform data quality review to validate code assignment and compliance with reporting requirements such as outpatient prospective payment system
  31. Ensure accuracy of diagnostic/procedural grouping such as DRG, APC, and soon
  32. Comprehend basic descriptive, institutional and health care vital statistics.
  33. Communicate with providers to discuss documentation deficiencies
  34. Participate in clinical documentation improvement programs to ensure proper documentation of health records.
  35. Collaborate with other departments on monitoring accounts receivable (i.e. unbilled, uncoded)
  36. Provide ongoing education to health care providers (i.e. regulatory changes, new guidelines, payment standards, best practices, etc.)
  37. Identify fraud and abuse
  38. Assist with appeal letters in response to claim denials
  39. Monitor claim denials/over-payment to identify potential revenue impact
  40. Prioritize the work according to accounts receivable, patient type, etc.
  41. Distribute the work according to accounts receivable, patient type, etc
  42. Maintain the Charge Master
  43. Ensure physicians are credentialed with different payers for reimbursement
  44. Respond to fraud and abuse
  45. Evaluate medical necessity
  46. Analyze data case mix index


TOPICAL OUTLINE:
  • Health care Reimbursement Methodologies
  • Voluntary Health Insurance Plans
  • Government-Sponsored Health care Programs
  • Managed Care Plans
  • Medicare-Medicaid Prospective Payment Systems
  • Ambulatory and Other Medicare-Medicaid Reimbursement System
  • Development of an Insurance Claim
  • Legal and Regulatory Issues
  • Commercial Insurance
  • Blue Cross
  • TRICARE
  • Worker’s Compensation
  • Hospital Claim form
  • Master Case Management
  • Required reporting and mandatory disclosure
  • RAC
  • Discuss the role of HIM in the Revenue Cycle and development of the Charge Master
  • Compliance
  • Medical Necessity
  • CMS 1500 Claim Form
  • Revenue Cycle
  • Charge Description Master
  • Case-Mix Management
  • Value Based Purchasing


TEXTBOOK / SPECIAL MATERIALS:
Casto, Anne, Forrestal, Elizabeth, Principles of Healthcare Reimbursement, 4th Edition AHIMA, 2013
Schraffenberger, Lou Ann, Duehn Lynn. Effective Management of Coding Services, 4th Edition AHIMA, 2013
Sayles, Nannette, edD, Health Information Management Technology: An Applied Approach, 4th Edition, AHIMA, 2013

EVALUATION:
A percentage system will be used to determine the course grade.  The grade will be based on classroom discussions, homework, online workbook assignments, special reports, tests, quizzes, and final.

The following competencies identified by the American Health Information Management Association are being addressed in this course.

BIBLIOGRAPHY:

REVISION:
Spring 2013

RECORD UPDATED:
2013-02-27 10:11:00