Reimbursement Systems

Masters Degree in Case Management

CSM 700

Breyer State University
Instructor: Darlene Amendolair RN, BSN , MN , MA, CNAA

SYLLABUS

COURSE OVERVIEW: The course will examine the complex financial systems within healthcare. The course is design to provide the student a thorough knowledge of the diverse reimbursement methodologies utilized throughout the governmental and private insurance entities and how they impact management of patients.

The course will discuss insurance and public funding programs to include Medicare and Medicaid programs and managed care contracting.

In today rising healthcare cost, the shrinking healthcare care dollar, the increase prosecution of false claims, and the substantial changes in reimbursement regulation, mastering the reimbursement process is very important for case managers. Patients are often having more than one payer, or have insurance that can be quickly exhausted or has limited or excluded benefits. Understanding the basics of health insurance and how services are paid is important to case managers.

TIME FRAME: This is a five-semester hour course. This course is allotted ten weeks of time. You must complete all the requirements for the course successfully by the end of the ten-week period. The first day of week one will begin the day that you register for the course, or the day, which you notify me that your textbook(s) have arrived and you are ready to begin your studies. Please be cognizant of the time frame. It is rare that extensions of tie are permitted, unless the student has good justification. Upon successful completion of this course, you will be awarded five semester hours of credit.

TEXTBOOK: There are two required textbooks for this course.

Book 1: Understanding Health Insurance: A guide to Bill and Reimbursement. (8th ed.) Rowell, J. & Green, M. Thomson Delmar Learning Publisher. 2005: ISBN # 1401895956.

Book 2: Nursing case management: From essentials to advanced practice application 4th ed. Cohen, E., Cesta, T. Elsevier Mosby 11830 Westline Industrial Drive, St. Louis, Missouri 63146. ISBN # 0-323-02765-2.

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GRADING: You will receive a letter grade based on your overall achievement. The course work will be 75% of your grade and the final paper will be 25%. The grading will be based on the following criteria:

GRADING SCALE:

90-100%    = A
80-89%      = B
70-79%      = C
Below 70% = Fail

ASSIGNMENTS: For specific assignments, please click on the link "Assignment". There will be ten written assignment, one per week. Each will require a 1-2 pages response. You can email your completed assignment to the address provided.

EXAMINATIONS: There will not be an examination for this course.

COURSE PAPER: At the end of the program, please submit a 10-15-page paper that demonstrates you accumulated understanding of the Healthcare Reimbursement process. Please submit your topic of interest by the end of Week 5.

INSTRUCTOR: My name is Darlene Amendolair RN, BSN , MN , MA, CNAA. I am a Nursing Management Professional with extensive experience in nursing and nursing administration in both military and civilian surgical settings. During nearly 30 years in the military, I obtained the rank of Colonel in the US Army Nurse Corps. I have successfully combined military experience, education, clinical knowledge and managerial skills to meet administration and leadership's challenges as a Surgical Administrator in several healthcare facilities. My primary area of expertise is in managing the business and clinical aspects of surgical inpatient and outpatient care. I hold Masters' degrees in both Nursing Administration and Resource Management, and I am currently pursuing my Ph.D. in Organization and Management with a specialization in Leadership. My area of interest is in development of nurses and nurse managers. I have presented lectures on leadership, financial management, and personnel management. My research interests have focused on leadership as it relates to gender and ethics in nursing as it relates to the business of healthcare. My hobbies include horseback riding, writing, art, woodworking (I like to build furniture), and caring for two horses and three dogs that are the size of small horses.

COMMUNICATIONS: You are encouraged to communicate with me. I am available to assist you in meeting your goals for this course. Primarily, communication is through email. However, I am also available for conversation by telephone if you would like.

COURSE OBJECTIVES: Upon completion of this course, you will be able to:

1). Understand the difference in health care plans and their methods of reimbursement.
2). Describe the services covered under Medicare and Medicaid.
3). Identify methods need to file claims under the various healthcare plans and advantages and shortcomings of electronic claims processing.
4). Describe the methods of coding, and the relations between coding, relative value weight, modifiers and optimizing good documentation to achieve maximum reimbursement.
5). Understand the general guidelines for ICD-9-CM, HCPCS coding system.
6). Know the standards that must be developed under HIPAA.
7). Explain the pre-claim submission operations and the impact to patient cost and healthcare reimbursement.
8). Become familiar with UB-9, HCFA 1500 Billing forms.
9). Understand why compliance programs are important in health care.
10). Understand the financial implications of APGs.
11). Describe the basic characteristics of DRG patient classification scheme.
12). Understand the relationship between clinical and financial implementation as it related to Home Health prospective payment system.
13). Understand the consolidated billing and new Medicare provisions for skilled nursing facilities.
14). Identify how clinical risk group will function in reimbursement.

REFERENCES:

Books:

Adams, D. (1997). Diagnosis documentation and coding: The key to reimbursement and capitation. : McGraw-Professional. ISBN: 0786310006.

Diamond, M., & Diamond, M. (2003). Coding Practice Supplement to Accompany Mastering Coding: An Applied Approach (2 nd ed.). Philadelphia : Saunders. ISBN: 0721603998.

Diamond, M. (2001). Mastering Coding: Tools, techniques and practice applications. Philadelphia : Saunders. ISBN: 0721690432.

Jones, L. (2001). Reimbursement methodologies for healthcare services. Chicago , Ill : American Health Information Management Association. ISBN 1-58426-055-6.

Rossi, P. (2003). Case management in health care (2 nd ed). Philadelphia , PA : Saunders.

Stace-Naughton, D. (1999). Coding reimbursement: The complete picture within healthcare. American Hospital Association. ISBN: 1556482442.

Articles:

(2001). Coping with home health PPS. Dennis Barry's Reimbursement Advisor, 16, 7, p12, 2p.

Abbey, D., & Blount, L. (1996). Understanding the financial implications of APGs. Healthcare Financial Management, 50, 10, p. 51, 5p.

Alexander, S., Conner, T., & Slaughter, T. (2003). Overview of inpatient coding. American Journal of Health System Pharmacists, 60, 6, p. S11-S14.

Brino, A. (2003). Proposed rule to modify rehab "75 Percent" rule. Dennis Barry's Reimbursement Advisor, 19, 3, p3, 4p.

Cote , J. & Latham, C. (2003). Exchanges between healthcare providers and insures: A case study. Journal of Managerial Issues, 15, 2, p. 191, 21p.

Davis, J. (2003). What steps are you taking to coordinate provider fraud and abuse inquires? Journal of Health Care Compliance, May-June 2003, p31-32.

Geisel, J. (2003). Insurers, managed care organizations roll out plans. Business Insurance, 37, 21, p.T10, 3/4p.

Grimaldi, P. (2002). Inpatient rehabilitation facilities are now paid prospective rates. Journal of Health Care Finance, 28, 3, p. 32, 17p.

Heinrich, J. (2001). Medicare home health care - OASIS data use, cost, and privacy implications. FDCH Government Account Report, 01/30/2001 .

Kelly, P. (2003). Will employee choice and defined contribution health plans salvage the embattled managed care system? Benefits Quarterly, 19, 3, p. 32, 19p.

Leary, R. & Farley, D. (2000). APCs: Reimbursement implications. Healthcare Financial Management, 54, 1, p38, 7p.

Little, M. (2001). New billing challenges under home health PPS. Dennis Barry's Reimbursement Advisor, 16, 8, p10, 3p.

Malatestinic, W., Braun, L., Jorgenson, J., & Eskew, J. (2003). Components of Medicare reimbursement. American Journal of Health-System Pharmacists, 60, 6, p. S3-S7.

McCall, N., Korb, J., Petersons, A., & Moore, S. (2002). Constraining Medicare home health reimbursement: What are the outcomes? Health Care Financing Review, 24, 2, p. 57, 20p.

Morrissey, J. (2003). HIPAA unplugged. Modern Healthcare, 33, 41, p8, 3p.

Skrine, R. (2002). Home care documentation. ASHA Leader, 7, 2, p16, 1/3p.

Tully, L., & Rulton, V. (2000). Evolution of the uses of ICD-9 coding: Medicare risk adjustment methodology for managed care plans. Topics in Health Information Management, 21, 2, p62, 6p.

Turner, G. (2002). A profile of the health sector in the United States . Pharmacoeconomics, 20, 3 supplement, p31-45.

Zarabozo, C. (2000). Milestones in Medicare managed care. Health Care Financing Review, 22, 1, p. 61-67.

Websites:

www.cms.hhs.gov - Centers for Medicare & Medicaid Services

www.managecareinfo.com - On-line information website on managed care

www.aahp.org - American Association of Healthcare Plans

www.ama.assn.org - American Medical Association

www.aapenatl.org - American Academy of Professional Coders

www.icd-9-cm.org - Central Office on ICD-9-CM

www.hcca-info.org - Health Care Compliance Association

www.acmaeb.org - American Case Management Association

www.insure.com/about.html - A website dedicated to information about health insurance

www.ahrq.gov - Agency for Healthcare Research and Quality

www.interqual.com - InterQual website

www.tricare.osd.mil - Tricare website

www.ha.osd.mil - Health Affairs website for information from the Office of CHAMPUS

www.cms,hhs.gov/hipaa/hipaaI/default.asp - Information on HIPAA and insurance reform through CMS

www.hiaa.org/consumer/guideltc.cfm - Health Insurance Association of America

www.oasisanswers.com - Home Care Resource information on OASIS documentation

http://aspe.os.dhhs.gov/daltcp/Reports/OASISapD.doc - Home Health Care Reimbursement OASIS assessment data.

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