STANDARD COMPETENCIES:

 

 1. Define key terms associated with health insurance processing.

 2. Explain principles of reimbursement in voluntary and government sponsored healthcare plans.

 3. Describe the differing types of organizations, services, and personnel and their interrelationships across health care delivery systems.

 4. Demonstrate how clinical data, clinical coding and coding compliance affect reimbursement .

 5. Utilize established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative.

 6. Explain how an organization can identify potential abuse or fraudulent trends through data analysis; including the role of OIG and RAC audits.

 7. Describe how revenue generating processes can trigger fraud surveillance.

 8. Explain how payment methodologies and systems work to capture data for reimbursement.

 9. Apply policies and procedures for the use of data required in healthcare reimbursement.

 10. Describe the revenue cycle processes.

 11. Evaluate the revenue cycle processes for improved efficiency.

 12. Apply policies and procedures as they relate to Quality/Compliance issues in Healthcare.

 

 

 TOPICAL OUTLINE

 

 I. Healthcare reimbursement methodologies

 II. Clinical coding and coding compliance

 III. Voluntary and government sponsored healthcare plans

 IV. Managed care plans

 V. Medicare-Medicaid Prospective Payment Systems for inpatients and post-acute care

 VI. Ambulatory and other Medicare-Medicaid reimbursement systems

 VII. Revenue Cycle Management Processes

 VIII. Data Capture for Reimbursement (capitation, PPS, RBRVS, case mix indices, MSDRGs, healthcare insurance policies, Accountable Care Organizations)

 IX. Summarize the roles of Utilization Review/ Management and Case Management in Revenue Management

 X. Data Accuracy and Integrity

 XI. Fraud Surveillance Systems surveillance (False Claims Act, STARK, Anti-kickback, unbundling, upcoding, etc.)

 XII. Quality/Compliance issues including Pay-for- Performance systems, coding, charge master, claims management and billing reconciliation processes.