Mar 28, 2024  
2020-2021 Catalog 
    
2020-2021 Catalog [ARCHIVED CATALOG]

MR 208 - Health Care Reimbursement


Credit Hours: 3

This course is designed to develop an understanding of the basic types of medical insurance programs available in today’s health care system. Practical applications of guidelines, conventions, and methodologies used in universal claims submissions, and reimbursement in various health care settings will be discussed. In addition, compliance with payer regulations and guidelines of various reimbursement systems will be introduced. 

Course Outcomes
Upon completion of this course, the student will be able to:

  • explain medico-legal issues and the professional and career responsibilities of a medical insurance billing specialist;
  • distinguish between basic insurance programs and contracts, including private insurance, managed care, Medicaid, Medicare, TRICARE, CHAMPVA, workers’ compensation, and other disability programs;
  • state the fundamentals of health insurance coverage and describe various types of health insurance programs;
  • demonstrate the use of source documents that relate to processing insurance claims;
  • describe the insurance billing specialist’s role in the collection process and name payment and credit options available to patients;
  • state ways to track reimbursement, interpret an explanation of benefits (remittance advice), and demonstrate completion of an authorization form, claim tracer, and an appeal;
  • demonstrate use of diagnoses coding utilizing the most current classification system;
  • demonstrate use of procedural coding utilizing the Current Procedural Terminology (CPT) reference book;
  • demonstrate completion of the HCFA-1500 claim form for private insurance, managed care, Medicaid, Medicare, TRICARE, CHAMPVA, and worker’s compensation carriers;
  • evaluate the key reimbursement systems in healthcare such as Diagnoses Related Groups, (DRG’s), Relative Value Studies (RVS), Resource Based Relative Value Scale (RBRVS) and the Ambulatory Payment Classification System (APC);
  • differentiate the relationship between various coding and classification systems utilized in the health care reimbursement process;
  • research and apply appropriate Federal, State, & Private Payer guidelines/regulations. (CMS, HCFA, Third Party Payers);
  • process claims for reimbursement to include:
    • manual and electronic preparation of claims;
    • tracing claims;
    • sequence of filing (eg. Primary vs. secondary);
    • reconciling payments/rejections; and
    • inquiry and appeal process.
  • apply managed care policies and procedures for referrals, re-certification and fee schedule payments; and
  • list ways of analyzing and controlling the payment collection process which includes: collecting/updating demographic data, billing cycles and itemization, aging/controlling accounts receivable and the collection process.


Prerequisites: MR 105, MR 106
F/S (N)