Insurance Procedures for the Medical Office: Medicare
I. Course Prefix/Number: HIT 115
Course Name: Insurance Procedures for the Medical Office: Medicare
Credits: 1 (1 lecture; 0 lab)
III. Course (Catalog) Description
Course provides in-depth study of Medicare insurance system. Focus is on knowledge of terminology and guidelines involved in claim filing process. Topics also include understanding of Medicare reimbursement policies, appeal rights, and CMS’s current efforts to curtail healthcare fraud and abuse.
IV. Learning Objectives
Upon successful completion of this course, the student will be able to:
- Comprehend Medicare basics: purpose, terminology, establishment, and eligibility
- Describe the Medicare’s physician enrollment process and provisions of provider agreement.
- Apply official Medicare’s guidelines to the claim filing process for claim submission.
- Apply Medicare reimbursement policies
- Demonstrate understanding of Medicare’s requirements for diagnosis and procedural code selection.
- Comprehend Medicare’s appeals process when challenging denied or disputed claim payment.
- Describe Medicare’s efforts to control and prevent fraud and abuse, as well as sanctions for noncompliance.
V. Academic Integrity and Student Conduct
• plagiarism (turning in work not written by you, or lacking proper citation),
• falsification and fabrication (lying or distorting the truth),
• helping others to cheat,
• unauthorized changes on official documents,
• pretending to be someone else or having someone else pretend to be you,
• making or accepting bribes, special favors, or threats, and
• any other behavior that violates academic integrity.
There are serious consequences to violations of the academic integrity policy. Oakton's policies and procedures provide students a fair hearing if a complaint is made against you. If you are found to have violated the policy, the minimum penalty is failure on the assignment and, a disciplinary record will be established and kept on file in the office of the Vice President for Student Affairs for a period of 3 years.
Please review the Code of Academic Conduct and the Code of Student Conduct, both located online at
VI. Sequence of Topics
- Overview of Medicare program
- Explain the purpose of the Medicare program
- Distinguish between the subdivisions of the Medicare program, and explain the basic coverage guidelines of each program.
- Explain the eligibility requirements for individuals granted coverage under the Medicare program.
- Analyze the Medicare internet site created for beneficiaries of the Medicare program.
- Physician enrollment and basic provisions of program
- Identify the different types of providers who are eligible for enrollment in the Medicare program.
- Explain the importance of the different provider numbers, and describe when each is required for billing purposes.
- Explain the difference between participating provider status and nonparticipating provider status.
- Define “assignment” and explain how it relates to billing Medicare services.
- Medicare claim filing process
- Explain the Part B claims submission requirement to Medicare carriers.
- Apply the instructions for completing the CMS 1500 claim form to case scenarios.
- Identify the types of supplemental insurance.
- Explain the role and claim filing instructions of a Medicare Secondary payer.
- Medicare Reimbursement
- Recognize “approved charge”, “assignment”, and “limiting charge”, and know how they impact Medicare reimbursement for covered services.
- Describe restrictions that nonparticipating providers must adhere to when filing claims.
- Define “advance beneficiary notice” and explain under which circumstances Medicare providers are subject to provide notice.
- Explain the billing requirement when a waiver of liability is obtained from the patient.
- Explain the provisions of private contracting with Medicare beneficiaries.
- Explain Medicare’s definition of Medical Necessity and describe how it relates to billing Medicare services.
- Define RBRVS and understand the individual components.
- Analyze a current Medicare Locality Fee Schedule.
- Coding guidelines and National Coverage Decisions
- Be familiar with accessing the National Coverage Decisions, and know how to apply their guidelines to individual patient encounters.
- Define Medicare’s Correct Coding Initiative and understand the importance of its implementation.
- Understand the provisions of Medicare’s global surgery policy.
- Medicare appeal process for disputed claims
- Explain the five levels of medical review utilized in the Medicare appeals process.
- Medicare fraud and abuse prevention
- Explain Medicare’s separate definitions of fraud and abuse.
- Explain Medicare’s relationship with the OIG in addressing fraud and abuse.
- Explain the penalties of committing fraud and abuse.
- Recognize Medicare’s seven key elements that produce an effective compliance program.
VII. Methods of Instruction
This course will be presented in lecture-discussion format with in-class exercises utilized to practice and build skills. Internet sites that provide information about the Medicare program will be incorporated.
Course may be taught as face-to-face, hybrid or online course.
VIII. Course Practices Required
Students will be expected to prepare for each class by completing assigned readings and homework assignments. Participation in class discussions will help both student and professor to assess understanding of course material. All assignments must be submitted on due dates provided by the instructor, and should be neat and legible.
Course may be taught as face-to-face, hybrid or online course.
IX. Instructional Materials
X. Methods of Evaluating Student Progress
Students will be evaluated on homework assignments, and exams. Grades will be determined on a cumulative point basis, which will be averaged. Grade distribution is as follows:
Grade distribution is as follows:
A = 94%
B = 88%
C = 82%
D = 76%
F = Below 76%
XI. Other Course Information
Attendance: Class attendance is expected. Absences should be reported to the instructor before the start of class, or as soon as possible in the case of an emergency. It is the student's responsibility to arrange to make up the work and to find out what assignments were given.
Students who inform the instructor in advance (at the beginning of the semester) of an intended absence for a MAJOR religious observance will not be penalized. However, instructors are not responsible for teaching material again and missed work, tests and quizzes must be made up either in advance or immediately following the intended absence.
Code of Student Conduct: Refer to college catalog.
Make-up of Exams - Make-up of exams will be allowed when students contact the instructor prior to the exam being given. Students will have one week from the date of the exam. Exams will be made up in the testing center unless other arrangements are made with the instructor.
Incomplete grades - It is the student's responsibility to initiate requests for an “incomplete” and to follow through with the procedure to remove the incomplete grade.
Late assignments - Late assignments will be accepted if the student has made arrangements with the instructor prior to the due date. An automatic 10% reduction of the grade will be applied.
If you have a documented learning, psychological, or physical disability you may be entitled to reasonable academic accommodations or services. To request accommodations or services, contact the Access and Disability Resource Center at the Des Plaines or Skokie campus. All students are expected to fulfill essential course requirements. The College will not waive any essential skill or requirement of a course or degree program.
Oakton Community College is committed to maintaining a campus environment emphasizing the dignity and worth of all members of the community, and complies with all federal and state Title IX requirements.
Resources and support for
- pregnancy-related and parenting accommodations; and
- victims of sexual misconduct
Resources and support for LGBTQ+ students can be found at www.oakton.edu/lgbtq.