BTAC 248 - Healthcare Reimbursement Methodology

1. Explain the use and impact of coded data and health information on claim reimbursement.
2. Identify the payment system appropriate to all healthcare setting; clinical, inpatient and outpatient.
3. Compare and contrast the managed and non-managed care reimbursement models including the use of capitation.
4. Research the most current forms of health insurance prospective payment systems (HIPPS) used for correct reimbursement for all healthcare settings; inpatient prospective payment systems (IPPS), outpatient prospective payment systems (OPPS), ambulatory payment classification system (APC’s) and more.
5. Compare and contrast the CMS-1500 form to the UB-92 form.
6. Execute general guidelines for completing both UB-92 and CMS-1500 forms for federal, state and private payer insurance contracts.
7. Define clinical and facility charge masters.
8. Explain the importance of maintaining charge masters routinely and understand the impact to an organization if routine maintenance is not performed.
9. Apply appropriate reimbursement compliance standards to all billing and coding scenarios.
10. Define the use of relative values units (RVU’s) and the Resource Based Relative Value Scale (RBRVS) in determining fee schedules, predicting compensation and planning budgets.
11. Describe legal and ethical issues specific to the medical billing function.
12. Describe the impact of the federal government Health Insurance Portability and Accountability Act (HIPAA) on medical billing.
13. Describe basic healthcare policy provisions and contracts.
14. Explain the basic steps for verifying eligibility and processing medical claims, including submitting claims via electronic data interchange (EDI), reading remittance advices (RA’s) and using advance beneficiary notices (ABN’s) when appropriate.
15. Handle insurance claims in the physician’s office to obtain payment and minimize claim rejection by insurance carriers.

1. Identify the different types of healthcare providers, disciplines, common departments and general structure found within healthcare organizations.
2. Apply legal principles, policies, regulations, and standards for the control and use of health information.
3. Perform mathematical calculations needed to process a claim, determine allowed amounts, deductibles and co-payments, process cash, check and electronic payments, and balance monthly and yearly financial records.

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