College of Health Professions2011 – 2012

HINT250 - Introduction to Reimbursement Systems (Formerly HSAD25

Credit Hours: 3 Prerequisite(s): ENGL109 and MATH125

Course Description

This course is an introduction to health care reimbursement systems found in medical offices, physician medical specialties, ambulatory service locations and hospitals. Students gain a detailed understanding of third party payers, payment methodologies (managed care, capitation, prospective payment systems, fee schedules, etc…), and chargemaster content and maintenance. Students acquire knowledge of health claims processing procedures and regulatory guidelines and compliance.

Learning Outcomes

Upon successfully completing this course, the student will be able to:

Communicate healthcare billing and reimbursement processes and procedures (such as CMS1500 and CMS450/UB04 claim forms, Explanation of Benefits, Advance Beneficiary Notices, and Electronic Data Interchange) practiced across the continuum of care.

Illustrate why professionalism is important in health care reimbursement. Compare and contrast commercial, managed care and federal insurance plans. Define third party payers. Analyze and appraise payment and reimbursement systems in healthcare delivery systems in the United States Break down payment methodologies and systems (such as capitation, prospective payment systems, Resource Based

Relative Value Scale). Analyze and perform chargemaster maintenance. Combine knowledge-based research techniques (such as library, MEDLINE, web-based) and common software

applications (such as word processing, spreadsheet, database, graphics) to facilitate learning outcomes Assess professional and practice-related ethical issues as they pertain to healthcare reimbursement systems. Interpret regulatory guidelines (such as Local Coverage Decisions/Local Medical Review Policies, peer review

organizations/Quality Improvement Organizations) and discuss their role in the payment process. Interpret compliance strategies and reporting. Describe the role of Health Insurance Portability and Accountability Act (HIPAA) of 1996 plays in healthcare billing

and reimbursement in the United States today. Carry out reimbursement monitoring and reporting. Discuss diagnostic and procedural groupings (such as DRG, APCs, ASC Groups, RUGs, SNOMED), case mix

analysis and indexes, coding compliance strategies, auditing and reporting (such as CCI, OIG Work Plans), and coding quality monitors and reporting.

Explain billing and reimbursement for healthcare services using codes. List classifications, taxonomies, nomenclatures, terminologies and clinical vocabularies used in healthcare

reimbursement systems.

Required Textbooks and Additional Materials

978-1-58426-243-5Principles of Healthcare Reimbursement - With CD / 3RD 11 EditionCasto, Anne B.American Health Information Management Association, New Only

DU Excellence System The Davenport University Excellence System consists of nine learning outcomes that demonstrate professional competencies necessary for graduates to engage in life-long learning and succeed in their chosen profession. These learning outcomes are

reinforced throughout the curriculum of each academic program and are assessed at the course and program levels, where appropriate. The Excellence System covers:

Global and Intercultural Competence Civic and Social Responsibility Ethical Reasoning and Action Critical and Creative Thinking Analysis and Problem Solving Leadership and Teamwork Information and Technology Proficiency. Written Communication Professional Communication

Academic IntegrityDavenport University recognizes the principles of honesty and truth as fundamental to ethical business dealings and to a vibrant academic community of faculty and students. All members of an academic community shall be confident that each person's work has been responsibly and honorably acquired, developed and presented. The work that a student submits shall be a fair representation of his/her ability, knowledge and skill. The University expects students to respect and exhibit these principles as they form the basis of the quality of the institution and the quality of Davenport’s graduates.

As stated in the Student Code of Conduct, the University may discipline a student for academic dishonesty which is defined as any activity that tends to undermine the academic integrity of the institution. Academic dishonesty includes, but is not limited to: cheating, fabrication, facilitating academic dishonesty, interference, plagiarism, or violation of course rules. Definitions, procedures, and sanctions for these violations may be found in the Student Code of Conduct.A minor violation occurs the first time the student has a breach of academic integrity and typically involves an assignment or activity that does not represent a significant part of the course grade. For example, the student knowingly and intentionally cheats on a weekly assignment; copies a source without proper citation; etc.

A major violation occurs as a first violation on an assignment or activity that is a significant part of the course grade, such as an exam or major paper, or as the result of a second minor violation.

Students are expected to review the complete Academic Integrity policy in the University catalog under Academic Policies and Procedures.

The University utilizes Turnitin.com plagiarism detection software. All papers will be submitted to Turnitin.com where they will be compared against the entire Internet and against a database of previously submitted student papers.

ADA StatementStudents with disabilities may request accommodations as provided within federal law. In order for the University to adequately review each case, requests should be made to the Disability Services Coordinator prior to the start of the semester. Requests made after the start of the semester should be completed as early in the semester as possible to prevent delays in accommodation. Students may contact their advisor or go to the Davenport University website for the name of the Disability Services Coordinator for the location where they attend. This must be done each and every semester in which the student is seeking accommodation.

Military AssistanceDavenport University recognizes the extraordinary contributions of the members of our armed services.  Service members and their dependents should check the DU website for educational benefits. Davenport University is committed to ensuring continuity of study for every active service member who is prohibited from completing a semester as planned due to reassignment or deployment. Service members should work with their DU military specialist prior to deployment to ensure proper preparation and handling of DU financial records and academic coursework so that academic re-integration is as seamless as possible upon return.

Student Responsibilities Students are bound by all policies of Davenport University and should familiarize themselves with these through reading the catalog and student handbook. Students should review the tuition refund policy found on the DU website.

All students must complete the final assessment for the course, such as the final exam, project, or presentation. Students who do not complete the final assessment will receive a grade of F.

Students are expected to be adequately prepared for each class session. It is reasonable to expect at least two hours of outside study for every hour spent in the classroom.

Students are expected to assist in maintaining a classroom environment that is conducive to learning. Therefore, free discussion, inquiry, and expression are encouraged. Behavior that interferes with the instructor’s ability to conduct the class or the ability of students to benefit from that instruction is not acceptable.

Alternative Delivery StatementAlternative delivery formats require considerably more student time outside of class and maintain the same level of assignments and academic rigor as the traditional classroom format. “Blended inseat w/online” is an example of an alternative delivery format.

Scheduled Class Meeting TimesThe state dictates minimal contact hour requirements that are rigidly upheld by the University. Some of that instructional time is used for tests. The University's expectation is that classes will meet for the entire assigned time.

Standardized Grade ScaleThe following grading scale is a University standard for courses in this area of study:

A 100 – 93 B- 82 – 80A- 92 – 90 C+ 79 – 77B+ 89 – 87 C 76 – 73B 86 – 83 F 72 – 0

Note: A grade of C or better is required to pass this course successfully.

Course Grade Determination:20% Weekly Quizzes30% Mid-Term Exam 20% Required Project30% Comprehensive Final Exam

Reservation StatementThe instructor reserves the right to make adjustments to this syllabus as needed.

Division RequirementsStudents are strongly encouraged to keep textbooks and instructional material after they have completed this course. These materials will be a valuable resource as they study and prepare for certification exams after graduation.

AHIMA Entry-level Competencies and Knowledge ClustersStudents successfully completing this course will meet a set of predetermined competencies, knowledge clusters and domains in the field of health information management. These competencies, knowledge clusters and domains have been predetermined by the American Health Information Management Association (AHIMA) and are available from the Instructor and published in the School of Health Professions Student Handbook.

Accreditation RequirementThis course is part of an accredited degree program. To maintain accreditation, we are required to document how we are meeting educational standards for accreditation. To meet this requirement we must show written proof. DU must collect copies of each assessment given to students, including quizzes and exams, which documents coverage of each entry-level competency, knowledge cluster and domain and the competency level assessed in this course.

Required Assessment/Project:This course includes a project/assignment that is required by the School of Health Professions. The details of this assignment have been designed by the faculty in the School of Health Professions and will be presented and assessed in a consistent and uniform manner. The following information will provide the detail necessary to meet the guidelines set forth by the faculty and approved by the School Dean. This assignment is a required component of this course and meets all Learning Outcomes in the course.

Description: This project demonstrates the student’s knowledge of content, comprehension, and understanding of healthcare reimbursement systems identified in the Learning Outcomes, including the administrative functions important in medical practices and an understanding of how to work with third-party payers and regulatory agency representatives.

Criteria: Representative selections from different aspects of healthcare reimbursement will be compiled into a project demonstrating the student’s understanding of health information management concepts required to manage healthcare reimbursement. Each required document is to be typed using APA format with all sources cited.

The Student must research and submit the following documents. Each document is to be, at minimum, 2 pages in length following APA format and excluding cover sheet and reference page(s). Project is 20% of the course grade. 1. Report on the importance of professionalism in health care and how one identifies a health care professional.

Describe characteristics and behaviors that demonstrate a commitment to the profession. Discuss the importance of character, values, morals, ethics and other personal traits. Explain how personal image and personal skills affect one’s professional reputation. Identify how you will develop and strengthen professional traits and behaviors to excel in your chosen profession.

2. Summary of billing processes and procedures including: Content and use of Registration and/or Encounter Forms Explanation of Benefits (EOB), Advance Beneficiary Notice (ABN), Remittance Advice (RA), and Participation

Contracts. The adjudication process for payers and providers.

3. Report outlining the differences between facility (hospital) claims processing and professional (provider) claims processing and the completion of each major claim form (CMS1500, CMS1450/UB92/UB04).

4. Comparison of the contents of commercial, managed care and federal healthcare plans.

5. Comparison of major healthcare payment and reimbursement systems found in the U.S. and two other countries (of the student’s choice).

6. Outline of the different prospective payment systems (PPS) currently in use in the United States including: Describe of the type of diagnostic and procedural groupings used in each PPS (not each individual grouping within

each PPS; for example, we are not looking for a description of each DRG but a description of DRGs in general). Provide an example of each PPS, what they are and why they are used in the U.S.

7. Report on the history of Local Coverage Decisions (or LCDs). Provide two current (within the past 12 months) examples of LCDs currently active in your regional Medicare

intermediary. Explain how each of these LCDs is used in the payment practice.

8. Report on Health Insurance Portability and Accountability Act (HIPAA) and its impact on healthcare claims processing, including electronic forms defined and contents of each as part of the mandatory electronic data interchange (EDI) including 835/837, ICD-10 and version 5010.

9. Utilizing graphs and charts, compare the classifications, taxonomies, nomenclatures, terminologies and clinical vocabularies used in healthcare claims processing. Include definition, required format, and use of each.

10. Report on the role of the Office of Inspector General (OIG) in coding compliance, auditing and reporting. Select two audits from the current OIG Work Plan and describe the focus and intent of each of these audits.

11. Report on your state’s Quality Improvement Organization (QIO). Describe the history of the organization, current Medicare projects, and services, projects and initiatives offered to

others within the healthcare industry. Describe how QIOs are integrated into the day-to-day operations of the healthcare organization.

12. Report on the role of the Federal Register in the healthcare claims processing profession. Give examples of current proposed and final rules that may affect the profession.

13. Project reflection: reflect on what you have learned by doing the research and completing the above assignment. Describe how you can apply this new knowledge in a new context, such as a new job. How might completion of this project guide your future behavior? Be sure to include the learning outcomes and references when appropriate.

Tentative Schedule

HINT 25012-week format

Week 1 5/17/12

Review Syllabus / Course Project Chapter 1 Health Care Reimbursement Methodologies

Week 2 5/24/12Quiz 1

Speaker – Library Services Chapter 2 Clinical Coding and Coding Compliance Project Review #1/Video: Professionalism

Week 3 5/31/12Quiz 2

Chapter 3 Voluntary Health Care Plans Chapter 4 Government-Sponsored Healthcare Programs

Week 4 6/7/12Quiz 3/4

Project 1 – Professionalism Due Project Review 10 - OIG and 11 – QIO

Week 5 6/14/12

Chapter 5 Managed Care Plans Chapter 6 Medicare-Medicaid Prospective Payment Systems for Inpatients

Week 6 6/21/12Quiz 5/6

Midterm Exam Review Project Review- 8 HIPAA and 9 Classifications and 12 - Federal Register

Week 7 6/28/12

Midterm Exam Chapter 7 Ambulatory and Other Medicare-Medicaid Reimbursement Systems

Week 8 7/5/12Quiz 7

Chapter 8 Medicare-Medicaid Prospective Payment Systems Post-Acute Care Project 8, 9,10, 11 and 12 – Due

Week 9 7/12/12Quiz 8

Chapter 9 Revenue Cycle Management Review Project 5 – Payment systems/other countries and 6 – US PPS

Week 10 7/19/12Quiz 9

Chapter 10 – Value Based-Purchasing Review Project 2 – Summary of billing process and 3 Compare facility/professional

Week 11 7/26/12Quiz 10

Final Exam Review Review Project 4 – Compare healthcare plans and 7 – LCD’s

Week 12 8/2/12

Project 2, 3, 4, 5, 6 , 7 and 13– Due Comprehensive Final Exam