You are here: Home instructional_framework official_framework Business and Information Technology Education Patient Billing & Medical Insurance
Navigation
Log in


Need a new SSL certificate?
 

View Career Major Course

Course Information
Business and Information Technology Education
BT00281
Patient Billing & Medical Insurance
180.00
This course provides an overview of the medical office accounting procedures, introduces you to the features of a patient billing system, and presents important concepts relating to a medical office accounting function. Simulated practice allows the student to assume the role of a medical billing assistant in a doctor’s office using cutting-edge patient billing software.
Jaimee Sizemore
Instructional Coordinator
Ph: (918) 828-5093
Foundations of Medical Office Assistant/Medical Terminology
A. Origins of Health Insurance.
1. Explain health (medical) insurance.
2. Describe the two basic types of health insurance plans and how each functions.
3. List the major sources of health insurance and briefly explain each.
4. Assess the benefits of the various healthcare coverage options.
5. Discuss the purpose and function of the Consolidated Omnibus Budget Reconciliation Act (COBRA).
6. Evaluate the importance of the health insurance “watchdogs.”
7. List and briefly define terms common to third-party carriers.

B. Legalities and Ethics of Medical Insurance.
1. Discuss employer/employee liability.
2. List and explain the elements of a legal contract.
3. Name and briefly discuss important legislative acts affecting health insurance.
4. Compare and contrast medical ethics and medical etiquette, and explain their importance in the workplace.
5. Identify HIPAA’s primary objectives.
6. Discuss HIPAA’s impact on healthcare personnel and patients, providers, and businesses.
7. Demonstrate an understanding of privacy/confidentiality laws.
8. List the exceptions to privacy/confidentiality laws.
9. Define and contrast fraud and abuse.
10. Analyze cause and effect of fraud and abuse in healthcare.
11. List ways to prevent fraud and abuse in the medical office.

C. Understand Medicaid.
1. Summarize the development and structure of Medicaid.
2. Outline population groups that are eligible for Medicaid coverage.
3. Determine the time frame for submitting a traditional Medicaid claim.1
4. Determine the maximum time frame for filing an appeal for a Medicaid claim.1
5. Define and apply the theory of reciprocity.1
6. Identify Medicaid groups that are impacted by premiums and cost sharing.
7. Discuss the role of managed care in Medicaid.
8. Outline the Medicaid claim process.
9. Interpret third-party liability as it relates to Medicaid.
10. List ways to avoid common Medicaid billing errors on CMS-1500 forms.
11. Demonstrate an understanding of the Medicaid standard remittance advice.
12. Explain terminology associated with the billing process.
13. Define fraud and abuse and how it affects the Medicaid program.
14. Discuss Medicaid quality practices.
15. Explain the health insurance professional’s role in optimizing Medicaid’s implementation.

D. Understand Medicare.
1. Identify which agency issues the UPIN codes.1
2. List and discuss Medicare combination coverages (i.e., Medi-Medi, Medigap, and Medicare Secondary Policy).
3. Determine benefits for Parts A, B, C, and D of Medicare.1
4. Identify the information on a Medicare health card.1
5. Determine the qualifications for Medicare disability coverage.1
6. Define the basis of fraud for Medicare purposes.1
7. Determine a primary and secondary payers for Medicare claims.1
8. Summarize the basics for filing Medicare claims electronically.
9. Describe the types of claims handled by fiscal intermediaries.1

E. Understand MILITARY CARRIERS.
1. Determine eligibility.1
2. Identify the plans and the Fiscal Intermediary.1
3. Discuss the role of the military health programs.
4. Outline the TRICARE program, including eligibility and enrollment options.
5. Describe TRICARE’s supplemental programs.
6. Explain the process of verifying TRICARE eligibility.
7. Distinguish between how TRICARE participating providers (PARs) and nonparticipating providers (nonPARs) submit claims.
8. Recap TRICARE’s cost sharing requirements.
9. Describe the TRICARE claims process.
10. Explain the CHAMPVA program, including eligibility.
11. Discuss what the Department of Defense (DoD) has done to implement HIPAA’s privacy rules.

F. Claim Submission Methods.
1. Explain the difference between electronic and paper claim submission.
2. Explain the development and expansion of electronic claims.
3. Discuss the HIPAA’s Administrative Simplification Compliance Act (ASCA) and its impact on electronic claims.
4. Determine the rationale for the new HIPAA 5010 Standards.
5. Outline the electronic billing process, and list essential elements for claim submission.
6. Explain the development and expansion of electronic claims.
7. Discuss the HIPAA’s Administrative Simplification Compliance Act (ASCA) and its impact on electronic claims.
8. Determine the rationale for the new HIPAA 5010 Standards.
9. Outline the electronic billing process, and list essential elements for claim submission.
10. Explain the development and expansion of electronic claims.
11. Discuss the HIPAA’s Administrative Simplification Compliance Act (ASCA) and its impact on electronic claims.
12. Determine the rationale for the new HIPAA 5010 Standards.
13. Outline the electronic billing process, and list essential elements for claim submission.
14. Outline the procedure for submitting claims involving secondary coverage.

G. Understand Managed Care.
1. Explain the concept of managed care.
2. List and briefly explain the common types of managed care organizations (MCOs).
3. Evaluate the advantages and disadvantages of managed care.
4. Examine how the goals of the Affordable Care Act fit those of managed care.
5. Discuss the rationale for certification and regulation of MCOs.
6. Explain the function of preauthorization, precertification, and referral.
7. Discuss HIPAA’s influence on managed care.
8. Describe the impact of managed care on the patient-provider relationship.
9. Analyze the future predictions of managed care.

H. Demonstrate Knowledge of Medical Billing.
1. List and discuss various patient expectations.
2. Name two future trends in the patient-practice relationship.
3. Explain various regulations in the Health Insurance Portability and Accountability Act (HIPAA) that affect patient billing.
4. Outline appropriate patient billing policies and practices.
5. Discuss billing and collection strategies in healthcare practices.
6. List federal regulations affecting credit and collection.
7. Explain two conventional collection methods.
8. Assess the benefits of a billing service.
9. Compare the advantages and disadvantages of using a collection agency.
10. Outline the steps involved in the small claims litigation process.

I. The Medical Record
1. State the basic purposes and components of a medical record.
2. Describe the issues of medical record ownership, retention, access, and release.
3. Discuss the requirements of appropriate medical record documentation.
4. List legal/ethical responsibilities of ancillary staff members.
5. Explain how computers have impacted health insurance.
6. Discuss the role of the Health Insurance Portability and Accountability Act (HIPAA) in electronic transmissions.
7. Describe the essential elements of electronic data interchange (EDI).
8. Explain the final “rule” for electronic submission of Medicare claims mandated under Administrative Simplification and Compliance Act (ASCA).
9. List and describe additional electronic services available to the health insurance professional.
10. Describe an electronic medical record (EMR) and the two types of EMR hybrids.
11. List potential issues of EMRs.
12. Discuss the future of EMRs, including privacy concerns for patients.
13. Explain how federal funding for EMR trials relates to “meaningful use.”

J. Explain Workers’ Compensation and Disability Insurance.
1. Explain the history and purpose of workers’ compensation.
2. Identify legislation that provided benefits for various categories of federal workers.
3. Discuss workers’ compensation eligibility requirements and exemptions.
4. Explain workers’ compensation benefits, denial of benefits, and appeals.
5. Discuss time limits for filing workers’ compensation claims.
6. Summarize the workers’ compensation claim process, including special billing notes.
7. Discuss workers’ compensation and managed care.
8. Explain HIPAA’s connection to workers’ compensation.
9. State methods for preventing workers’ compensation fraud.
10. Summarize the workers’ compensation claim process, including special billing notes.
11. Discuss workers’ compensation and managed care.
12. Explain HIPAA’s connection to workers’ compensation.
13. State methods for preventing workers’ compensation fraud.

K. Understanding Indemnity (fee-for-service) Plans.
1. Describe traditional fee-for-service (FFS; indemnity) insurance.
2. Explain how an FFS plan works.
3. Discuss healthcare reform and preexisting conditions.
4. Define the components of commercial/private insurance.
5. Differentiate between PARs and nonPARs.

1ODCTE objective
The class will primarily be taught by the lecture and demonstration method and supported by various media materials to address various learning styles. There will be question and answer sessions over material covered in lecture and media presentations. Supervised lab time is provided for students to complete required projects. Students are graded on theory and shop practice and performance.
ICD-9 and ICD-10
American Academy of Professional Coders (AAPC)
Health Insurance Today-A Practical Approach: Workbook and Textbook, 5th Edition, Janet Beik, Elsevier Saunders, 2015
No
No
Yes
No
Career Majors That Sequence This Course
Career Cluster Pathway Career Major
Business Management & Administration Business Information Management Medical Coding