What You Will Learn in HIM 7007: Healthcare Reimbursement System

In this course, students will explore the complexities of the healthcare reimbursement system, including the coding and billing practices that determine how healthcare providers are paid for their services. The course will cover reimbursement models, payer policies, and the regulatory environment that governs healthcare billing. Students will also learn about the financial implications of reimbursement and the role of HIM professionals in ensuring proper documentation, compliance, and reimbursement accuracy.

Key Topics Covered in HIM 7007: Healthcare Reimbursement System

The course covers a wide range of topics critical to understanding the healthcare reimbursement process:

Overview of Healthcare Reimbursement: Learn about the reimbursement process, the role of healthcare payers, and how reimbursement models impact healthcare organizations.
Coding Systems and Reimbursement: Study how ICD, CPT, and HCPCS codes are used in the reimbursement process to document services and procedures. Understand the importance of accurate coding for appropriate reimbursement.
Government Programs and Payers: Explore the reimbursement structures of government programs like Medicare, Medicaid, and CHIP, as well as private payers, including insurance companies and managed care organizations.
Medicare and Medicaid Reimbursement: Dive deep into the reimbursement methodologies for Medicare and Medicaid, including Diagnosis-Related Groups (DRGs), Prospective Payment Systems (PPS), and other methodologies used to determine payments.
Managed Care and Reimbursement Models: Learn about managed care organizations (MCOs) and the various reimbursement models used in the private insurance market, including capitation, fee-for-service, and bundled payments.
Reimbursement Policies and Compliance: Study the policies that govern reimbursement, including the regulatory environment and compliance requirements, such as the False Claims Act and the role of HIM professionals in ensuring compliance.
The Role of the HIM Professional in Reimbursement: Learn how HIM professionals contribute to the reimbursement process by ensuring accurate documentation, coding, and compliance with payer policies.
Revenue Cycle Management: Explore the steps involved in revenue cycle management, from patient registration to claims submission and payment collection, and understand how proper reimbursement impacts the financial success of healthcare organizations.
Challenges and Trends in Healthcare Reimbursement: Understand the challenges healthcare organizations face in the evolving reimbursement landscape, including the shift to value-based care, bundled payments, and the impact of healthcare reforms.

Learning Objectives of HIM 7007: Healthcare Reimbursement System

By the end of this course, students will:

Understand the fundamentals of the healthcare reimbursement system, including the key players, reimbursement models, and payment structures.
Be proficient in applying ICD, CPT, and HCPCS coding systems to ensure accurate documentation for reimbursement.
Understand the various government reimbursement programs (e.g., Medicare, Medicaid) and their payment methodologies.
Develop an understanding of managed care reimbursement models and their impact on healthcare delivery.
Be knowledgeable about the regulatory requirements for reimbursement, including compliance with billing codes and payer policies.
Gain the ability to evaluate reimbursement policies and their financial impact on healthcare organizations.
Understand the importance of revenue cycle management and how it contributes to the overall financial health of healthcare organizations.
Learn to navigate challenges in the reimbursement system, including changing regulations and the transition to value-based reimbursement models.