Reimbursement Issues

I.     Course Prefix/Number: HIT 260

       Course Name: Reimbursement Issues

       Credits: 3 (3 lecture; 0 lab)

II.    Prerequisite

Consent of instructor or department chair.

III.   Course (Catalog) Description

Course provides comprehensive study of reimbursement procedures for prospective payment system, hospital outpatient services, and physician practices. Coding issues emphasized and optimization skills developed and applied in each area. Focus is on role of health information practitioner on financial performance in health care.

IV.   Learning Objectives

  1. Differentiate between the different types of healthcare reimbursement methodologies, including fee-for-service, episode-of-care and prospective payment systems as well as which payers utilize each of the systems.
  2. Explain the importance of coding compliance, a coding compliance plan, the relationship between coding compliance and reimbursement, and fraud and abuse prevention.
  3. Compare the different types of voluntary healthcare insurance plans, including individual healthcare plans, employer-based (group) healthcare plans, Blue Cross and Blue Shield plans, and state healthcare plans for the medically uninsurable.
  4. Describe the provisions and functioning of health insurance plans, sections of a health insurance policy, determination of covered services, remittance advice (RA) and explanation of benefits (EOB).
  5. Outline the covered services and populations for government-sponsored healthcare programs including Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D, Medigap plans, Medicaid, Children’s Health Insurance Program (CHIP), Veterans Health Administration, CHAMPVA, and worker’s compensation.
  6. Describe managed care plans, including the benefits and services, characteristics and types of managed care organizations (MCOs) as well as integrated delivery systems.
  7. Examine the conversion from cost-based payment to prospective payment for Medicare and Medicaid inpatients, the Diagnosis-Related Groups (DRGs) classification system, Medicare-Severity Diagnosis-Related Groups (MSDRGs) and the inpatient psychiatric facility prospective payment system.
  8. Calculate Diagnosis-Related Groups (DRGs), Medicare Severity Diagnosis Related Groups (MSDRGs), case mix index (CMI) and interpret relative weight (RW), CMI, the importance of CMI and changes to CMI. Evaluate the accuracy of DRGs.
  9. Explain the resource-based relative value scale (RBRVS) for physician and professional payments system, the structure of payment, calculation, and operational issues.
  10. Differentiate between the hospital outpatient prospective payment systems (HOPPS) and the ambulatory surgical center (ASC) prospective payment system including the payment methodology.
  11. Explain the ambulatory payment classification (APC) system, payment rates, separately payable services and the payment methodology for device-intensive procedures, multiple and bilateral procedures, and interrupted procedures.
  12. Compare the data collection and reporting, structure of payment and payment for Medicare-Medicaid Prospective Payments Systems (PPS) for postacute care including the Skilled Nursing Facility Prospective Payment System (SNFPPS), Long-Term Care Hospital Prospective Payment System (LTCHPPS), Inpatient Rehabilitation Facility Prospective Payment System (IRFPPS), and the Home Health Prospective Payment System (HHPPS).
  13. Describe the importance of a multidisciplinary approach to revenue cycle. management, the components of the revenue cycle including preclaims submission activities, claims processing activities, accounts receivable (AR), claims reconciliation and collection.
  14. Discuss the role of the Charge Description Master (CDM) including structure, maintenance and compliance.

V.    Academic Integrity and Student Conduct

Students and employees at Oakton Community College are required to demonstrate academic integrity and follow Oakton's Code of Academic Conduct. This code prohibits:

• cheating,
• 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

  1. Healthcare reimbursement methodologies
    1. Introduction to healthcare reimbursement
      1. National models of healthcare delivery
      2. United States healthcare sector
      3. Dominance of federal healthcare payment methods
      4. Health insurance
    2. Types of healthcare reimbursement methodologies
      1. Fee-for-service reimbursement
      2. Episode-of-care reimbursement
    3. Trends in healthcare reimbursement
      1. Constantly increasing healthcare spending
      2. Healthcare reform
      3. Use of health information and communication technologies
  2. Clinical coding and coding compliance
    1. The clinical coding-reimbursement connection
      1. The International Classification of Diseases (ICD)
      2. Healthcare Common Procedure Coding System (HCPCS)
    2. Coding compliance and reimbursement
      1. Fraud and abuse
      2. Oversight of Medicare claims payments
      3. Other third-party payer reviews
      4. Coding compliance plan
  3. Voluntary healthcare insurance plans
    1. Introduction to voluntary healthcare insurance
      1. Types of voluntary healthcare insurance
      2. Individual healthcare plans
      3. Employer-based (group) healthcare plans
      4. Blue Cross and Blue Shield plans
      5. State healthcare plans for the medically uninsurable
    2. Provisions and functioning of health insurance plans
    3. Sections of a healthcare insurance policy
      1. Definitions
      2. Eligibility and enrollment
      3. Benefits
      4. Limitations
      5. Exclusions
      6. Riders and endorsements
      7. Procedures
      8. Appeals processes
    4. Determination of covered services
    5. Elements of healthcare insurance identification card
    6. Filing a healthcare insurance claim
    7. Remittance Advice (RA) or Explanation of Benefits (EOB)
    8. Trends
  4. Government-sponsored healthcare programs
    1. Introduction
    2. Medicare
      1. Medicare Part A for inpatients
      2. Medicare Part B
      3. Medicare Part C
      4. Medicare Part D
      5. Medigap
    3. Medicare market basket updates: reductions and productivity
    4. Adjustments
    5. Medicaid
    6. Other government-sponsored healthcare programs
      1. Programs of all-inclusive care for the elderly
      2. Children’s Health Insurance Program (CHIP)
      3. Veterans Health Administration
      4. CHAMPVA
      5. The Indian Health Service
      6. Worker’s compensation
  5. Managed care plans
    1. Introduction to managed care
    2. Managed Care Organizations (MCOs)
      1. Benefits and services of MCOs
      2. Characteristics of MCOs
      3. Contract management
      4. Types of MCOs
    3. Integrated Delivery Systems (IDS)
      1. Integrated Provider Organization (IPO)
      2. Group (practice) without walls
      3. Physician-hospital organization
      4. Management service organization
      5. Medical foundation
    4. Consolidation
  6. Medicare-Medicaid Prospective Payment Systems (PPS) for inpatients
    1. Introduction to Inpatient Prospect Payment Systems (IPPS)
    2. Acute-care prospect payment system
      1. Conversion from cost-based payment to prospect payment
      2. Diagnosis-Related Group (DRG) classification system
      3. Assigning Medicare-Severity Diagnosis-Related Groups (MSDRGs)
      4. Provisions of the Medicare-Severity Diagnosis-Related Group System
      5. IPPS payment
    3. Inpatient Psychiatric Facility Prospective Payment System (IPFPPS)
      1. Patient-level adjustments
      2. Facility-level adjustments
      3. Provisions of the Inpatient Psychiatric Facili8ty Prospective Payment System
      4. Payment steps
  7. Ambulatory and other Medicare-Medicaid reimbursement systems
    1. Introduction to reimbursement systems for physicians and ambulatory settings
    2. Resource-Based Relative Value Scale (RBRVS) for physician and professional payments
      1. Background
      2. Structure of payment
      3. Calculation
      4. Potential adjustments
      5. Operational issues
    3. Hospital Outpatient Prospective Payment System (HOPPS)
      1. Hospital outpatient prospective payment methodology
      2. Ambulatory Payment Classification (APC) system
      3. Payment determination
    4. Ambulatory Surgical Center (ASC) prospective payment system
      1. Medicare certification standards
      2. Payment for ambulatory surgical center services
      3. Criteria for ambulatory surgical center procedures
      4. Ambulatory payment classifications and payment rates
      5. Separately payable services
      6. Device-intensive procedures
      7. Multiple and bilateral procedures
      8. Interrupted procedures
      9. ASC PPS payment
    5. Payment for safety-net providers
    6. Hospice services payment system
      1. Background
      2. Reimbursement
      3. Implementation
  8. Medicare-Medicaid Prospective Payment Systems (PPS) for postacute care
    1. Introduction to prospective payments systems in postacute care
    2. Skilled Nursing Facility Prospective Payment System (SNFPPS)
      1. Background
      2. Data collection and reporting
      3. Structure of payment
      4. Payment
    3. Long-Term Care Hospital Prospective Payment System (LTCHPPS)
      1. Background
      2. Data collection and reporting
      3. Structure of payment
      4. Payment
      5. Implementation
    4. Inpatient Rehabilitation Facility Prospective Payment System (IRFPPS)
      1. Background
      2. Data collection and reporting
      3. Structure of payment
      4. Payment
      5. Implementation
    5. Home Health Prospective Payment System (HHPPS)
      1. Background
      2. Data collection and reporting
      3. Structure of payment
      4. Payment
      5. Implementation
  9. Revenue cycle management
    1. Introduction to revenue cycle management
    2. Multidisciplinary approach
    3. Components of the revenue cycle
      1. Preclaims submission activities
      2. Claims processing activities
      3. Accounts receivable (AR)
      4. Claims reconciliation and collection
      5. Charge Description Master (CDM) structure, maintenance, and Compliance
  10. Revenue cycle management team
    1. Revenue cycle analysis

VII.  Methods of Instruction

The class will follow a participative lecture-discussion format.  There will be collaborative activities with emphasis placed on student involvement in the problem-solving process. Students will communicate their ideas in verbal and written format.

Course may be taught as face-to-face, hybrid or online course.

VIII. Course Practices Required

Students are required to attend classes, complete assignments, do required readings and participate in class discussions.  Participation in small groups and discussion are required, as well as proficiency in encoder software, internet resources, and use of Microsoft Office application, including Word, Excel, and PowerPoint.

IX.   Instructional Materials

Note: Current textbook information for each course and section is available on Oakton's Schedule of Classes.

Principles of Healthcare Reimbursement, Anne B. Casto, RHIA, CCS and Elizabeth Forrestal, PhD, RHIA, CCS, FAHIMA, AHIMA, Fifth Edition, 2015. Required.
Health Information Management Technology:  An Applied Approach.  Nanette B. Sayles, EdD, RHIA, CHP, CCS, CPHIMS, FAHIMA, AHIMA Fourth Edition, 2013. Required.

The Journal of AHIMA and other publications as assigned or posted to D2L site.

Encoding software: Quantim or 3M Encoder accessed through AHIMA Virtual Lab ICD-10-CM/ PCS and CPT coding books or encoders may be used for specific assignments.  Students may be asked to visit the AHIMA website to access additional information on topics covered in this course.

X.    Methods of Evaluating Student Progress

Evaluation will be based on assignments, projects, quizzes, presentations, and examinations on a cumulative point basis.

The HIT Grading scale is:

A = 94%
B = 88%
C = 82%
D = 76%
F = 75%

XI.   Other Course Information

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.

CAHIIM Curriculum Entry-Level Competencies for Health Information Management (HIM) at the Associate Degree Level

Entry-Level Competencies
1. Data Content, Structure & Standards
Subdomain I.A. Classification Systems
3. Apply diagnostic/procedural groupings
4. Evaluate the accuracy of diagnostic/procedural groupings
IV. Revenue Management
Subdomain IV. A. Revenue Cycle and Reimbursement
1. Apply policies and procedures for the use of data required in healthcare reimbursement
2. Evaluate the revenue cycle management processes
V. Compliance
Subdomain V. A. Regulatory
3. Adhere to the legal and regulatory requirements related to health information management
Subdomain V. C. Fraud Surveillance
1. Identify potential abuse or fraudulent trends through data analysis
VI. Leadership
Subdomain VI. F. Strategic and Organizational Management
2. Understand the importance of healthcare policy-making as it relates to the healthcare delivery system
3. Describe the differing types of organizations, services, and personnel and their interrelationships across the health care delivery system

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
can be found at

Resources and support for LGBTQ+ students can be found at

Electronic video and/or audio recording is not permitted during class unless the student obtains written permission from the instructor. In cases where recordings are allowed, such content is restricted to personal use only. Any distribution of such recordings is strictly prohibited. Personal use is defined as use by an individual student for the purpose of studying or completing course assignments.

For students who have been approved for audio and/or video recording of lectures and other classroom activities as a reasonable accommodation by Oakton’s Access Disabilities Resource Center (ADRC), applicable federal law requires instructors to permit those recordings. Such recordings are also limited to personal use. Any distribution of such recordings is strictly prohibited.

Violation of this policy will result in disciplinary action through the Code of Student Conduct.