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Reimbursement Methodology

Learn the basics of medical insurance billing and current payment methodologies in the inpatient, hospital outpatient, and physician’s office settings. The focus of this course is on compliance with regulatory requirements and common billing practices.

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You'll Walk Away with

  • Knowledge of the history of healthcare reimbursement in the United States
  • An understanding of the difference between government and nongovernment payers
  • Familiarity with the concept of the prospective payment system
  • Knowledge of the concept of managed care and the different types of HMOs
  • Familiarity with diagnosis-related groups (DRGs) and an understanding of how they affect hospital reimbursement, how CMI (Case Mix Index) is calculated, and how it reflects a facility’s financial standing
  • An understanding of how hospital-acquired conditions (HACs) may affect hospital reimbursement
  • Knowledge of how OP reimbursement is calculated and how OP claims are paid
  • The ability to differentiate between types of audits and auditing entities (RAC, IPRO, etc.)

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