This course covers the fundamentals of medical billing, coding, and reimbursement by explaining how all of these components work together. Emphasis will be placed on the practical application of the latest industry knowledge and standards, with the goal of helping those who work with medical claims and claims data stay ahead of the game.
Participants will learn about the following:
- The claim flow process from registration through adjudication and payment
- How physicians and hospitals set and manage charges
- Critical data elements on the two major claim forms and what they mean
- How and why the major coding systems are utilized
- How various reimbursement methods are used by payors
Why you should attend:
This course is organized into three sections:
1. Life cycle of a claim
Many people understand a portion of the claim adjudication process, but they may not have a complete understanding of all steps necessary to generate and adjudicate claims. We walk through the entire life cycle of a medical claim, from patient registration through provision of services, from claim generation to adjudication, from payment to posting. This is useful for anyone new to the healthcare industry or for persons who want a more complete understanding of the entire claim life cycle.
2. Coding systems
Medical coding is the foundation of the US healthcare system. Medical codes are essential for billing and claims, reimbursement, healthcare analytics, risk scoring, physician compensation, among many other uses. Every claim includes multiple codes from various coding systems. In this course, we explain the use of five of the most common schemes in use today: CPT and HCPCS codes, ICD-10 codes, DRGs, and APCs.
For each system, we discuss how codes are assigned; where they appear on the claim; how they are used for billing and reimbursement; which types of claims are subject to each coding scheme; and other features of each system. We also provide tips for analyzing data containing these codes.
3. Reimbursement explained
Healthcare reimbursement systems can be complex and difficult to understand. Each payor may use a different method to reimburse providers, or they may use a variation of a commonly used method. In the third portion of this course, we discuss the common reimbursement systems in use today. We start with Medicare's reimbursement systems of RBRVS, DRGs, and APCs because many other payors use modified versions of these systems. We then discuss other payor types such as HMOs, PPOs, and ACOs and how these organizations use other reimbursement methods such as capitation, per diems, and carve outs. Finally, we discuss the key data elements needed to adjudicate claims according to each scheme, and we discuss the financial incentives (and disincentives) associated with each method.
Section 1: Life Cycle of a Claim
- Setting charges – the hospital chargemaster and clinic fee schedule
- Process by which a claim is generated, from registration through discharge, and the role that each department plays in that process
- Important data elements on the UB04 and CMS-1500 and what they mean
- Role of the claims clearinghouse
- How payors adjudicate and pay claims
- How providers receive and post payments
- The back end: appeals, denials, adjustments, subrogation, etc.
Section 2: Coding
- How each coding system works
- When and why they're used
- How they affect charges and reimbursement
- CPT, HCPCS codes
- Diagnosis Related Groups (DRGs) and Major Diagnostic Categories (MDCs)
- Ambulatory Patient Classifications (APCs)
- ICD-10 diagnosis and procedure codes
Section 3: Reimbursement Explained
- Prospective Payment Systems: DRG and APC based reimbursement
- Typical hospital contracting structures: per diem, per stay, carve outs, case rates, minimum/maximums, etc.
- Physician fee schedules and fee maximums, RBRVS, RVUs and capitation
- Major payor types (Medicare, Medicaid, HMO, PPO, ACO, etc.) and how they reimburse providers
Chief Executive Officer ,
Rich Henriksen is the Chief Executive Officer and founder of Nokomis Health. Rich has 30 years of experience in healthcare systems, coding, billing, and reimbursement. He has led managed care departments and provider contracting units at a variety of organizations, including hospitals, clinics, and health plans. Rich has worked with over 70 different organizations, ranging from hospitals and clinics to third-party administrators, law firms, and internet-based companies. As a respected industry expert, he is well known for his unparalleled depth of knowledge in all aspects of healthcare coding, billing and reimbursement.
Rich received his Bachelor of Arts in biology from Luther College in Decorah, Iowa, and his Master of Arts in Healthcare Administration from The University of Iowa. He resides in Minneapolis, Minnesota where he leads the Nokomis Health team on their mission to set a new standard for medical claim review. Rich has previously trained staff at Optum, Prime Therapeutics, Definity Health, UCare Minnesota, TC Health, Essential Health, the American Association of Acupuncture and Oriental Medicine, and others. He has presented several times at SAS user conferences and other regional conferences.
An engaging instructor with an informal teaching style – making sessions enjoyable and easy to follow. Rich has taught this course to many professionals within the medical industry and incorporates feedback and suggestions from previous participants to evolve this incredibly insightful program. Rich allows time in the schedule for participants to ask questions.
- Health Information Managers
- Medical Billers
- Physicians and other Medical professionals
- Provider Contract Managers
- Medical Coders
- Claim Examiners
- Reimbursement Directors
- Payment Integrity Managers
- Quality Managers and Revenue Managers