Course Number and Title: HIM 222 Healthcare Reimbursement
In this course, students explore reimbursement and payment methodologies applicable to healthcare in the United States in various settings. Forms, processes, practices, and the roles of the health information professional are examined. Concepts related to insurance products, third-party and prospective payment, and managed care organizations are explored. Issues of data exchange among the patient, provider, and insurer are analyzed in terms of organizational policy, regulatory issues and information management operating systems. The importance of coding integrity is emphasized.
Allied Health/Science Department Program Student Policy Manual
Health Information Management Program Policy Manual
AHIMA Virtual Lab is used for this course. Neehr Perfect is used for this course.
- Analyze policies and procedures required in reimbursement and prospective payment systems in healthcare delivery to ensure organizational compliance with regulations. (CCC 2, 5; COD PGC 2, 3, 4; HIM PGC 1, 5, 6)
- Evaluate revenue cycle management processes to ensure data quality throughout the process. (CCC 2, 3, 5; COD PGC 2, 3, 4; HIM PGC 4, 5, 6)
- Explain the interrelationships among providers, payers, and government entities across the healthcare delivery system as they relate to reimbursement. (CCC 1, 5; COD PGC 1, 3, 4; HIM PGC 1, 3, 5, 6)
- Examine accounting methodologies. (CCC 1, 6; COD PGC 5; HIM PGC 1, 2, 5)
See Core Curriculum Competencies and Program Graduate Competencies at the end of the syllabus. CCPOs are linked to every competency they develop.
Upon completion of this course, the student will:
Analyze policies and procedures required in reimbursement and prospective payment systems in healthcare delivery to ensure organizational compliance with regulations.
Identify authoritative sources of regulations related to payment systems for healthcare services.
Identify ways to obtain regulatory agency and apply payer-specific guidelines for use in the coding and reimbursement process, including:
- National Coverage Determinations (NDCs)
- Local Coverage Determinations (LCDs)
- Quality Improvement Organizations (QIOs)
- Differentiate insurance plans, entitlement programs, and reimbursement methodologies.
- Differentiate the Medicare and Medicaid payment systems for the following settings:
- Inpatient (acute hospital)
- Hospital outpatient
- Inpatient psychiatric hospital
- Long-term care hospital
- Skilled nursing facility
- Inpatient rehabilitation hospital
- Home health
- Ambulatory surgery center
- Non-hospital outpatient services
- Determine health industry guidelines, rules, and regulations for commercial, managed care, and government payment systems.
- Compare and contrast health industry guidelines, rules, and regulations for commercial, managed care, and government payment systems.
- Examine policies and procedures related to reimbursement and prospective payment systems to ensure compliance with health industry guidelines, rules, and regulations.
Evaluate revenue cycle management processes to ensure data quality throughout the process.
Define revenue cycle management.
List and describe the components of the revenue cycle.
- Pre-encounter data collection and verification
- Patient access activities
- Order entry
- Charge description master
- Charge description master maintenance
- Claim scrubbing and validation
- Claim processing activities
- Claim submission
- Accounts receivable
- Insurance processing
- Benefits statements
- Remittance advice
- Claim reconciliation
- Describe and explain the rationale for the composition of the revenue cycle management team.
- Explain the role of utilization review/management, case management, and clinical documentation improvement in revenue cycle management.
- Calculate the expected reimbursement of a claim based on the appropriate payment methodology for the underlying setting.
- Evaluate a claim’s compliance with reporting requirements relevant to the underlying setting.
- Evaluate a denied claim scenario for the validity of the denial in the context of reporting requirements relevant to the underlying setting and make any necessary corrections.
- Explain the interrelationships among providers, payers, and government entities across the healthcare delivery system as they relate to reimbursement.
- Describe the impact of change in a given revenue cycle related regulation or standard on policies and procedures, processes, systems, and people.
- Explain the role of federal agencies and contractors in identifying waste, fraud, and abuse in healthcare reimbursement.
- Compare organizational results with secondary data sources for benchmarking reimbursement outcomes.
- Describe the impact of revenue cycle processes and staffing on department budgets in patient access, health information management, and patient financial services.
- Evaluate compliance with ethical standards of practice, given a case scenario.
- Examine accounting methodologies.
- Differentiate financial and management accounting.
- Describe cost accounting.
- Differentiate cost allocation methods.
- Given a set of financial statements, calculate basic financial ratios.
Students must demonstrate proficiency on all CCPOs at a minimal 75 percent level to successfully complete the course. The grade will be determined using the Delaware Tech grading system:
Students should refer to the Student Handbook for information on the Academic Standing Policy, the Academic Integrity Policy, Student Rights and Responsibilities, and other policies relevant to their academic progress.
Calculated using the following weighted average
Percentage of final grade
Lab assignments (summative)
Research Paper (summative)
Exams (Total 35%)
- Apply clear and effective communication skills.
- Use critical thinking to solve problems.
- Collaborate to achieve a common goal.
- Demonstrate professional and ethical conduct.
- Use information literacy for effective vocational and/or academic research.
- Apply quantitative reasoning and/or scientific inquiry to solve practical problems.
COD Program Graduate Competencies:
- Read and interpret medical record documentation in order to identify data for medical coding.
- Apply knowledge of medical sciences, medical terminology, current coding guidelines, and reimbursement guidelines to assign accurate codes to patient diagnoses and procedures in health record documentation.
- Adhere to standards of ethical coding and apply professional ethical guidelines to coding principles when assigning medical codes and/or processing claims.
- Apply regulatory agency guidelines to coding principles when assigning medical codes and/or processing claims.
- Recognize coding quality issues and participate in quality assessments in the coding and collection of quality health data.
- Demonstrate appropriate professional interactions and work skills in the workplace setting.
HIM Program Graduate Competencies:
- Synthesize knowledge of medical sciences, clinical classification systems, vocabularies, and terminologies to effectively use, apply, and interpret health data.
- Analyze data to identify trends through the use of health information technologies.
- Apply legal, regulatory, privacy, and security standards to employ policies and procedures for health information collection, access, and disclosure.
- Synthesize knowledge of health data and payment methodologies to evaluate the efficiency and effectiveness of revenue cycle processes.
- Interpret regulatory, coding, legal, and clinical documentation standards to develop, implement, and evaluate compliance.
- Consistently demonstrate leadership through the appropriate interpretation and evaluation of professional behaviors and ethical standards.
The College is committed to providing reasonable accommodations for students with disabilities. Students are encouraged to schedule an appointment with the campus Disabilities Support Counselor to request an accommodation needed due to a disability. A listing of campus Disabilities Support Counselors and contact information can be found at the disabilities services web page or visit the campus Advising Center.