Standard

Posted: 03/19/08

 R State Standard         £ Institutionally Developed          College: n/a

MAS 110 Medical Insurance Management

Course Description

Emphasizes essential skills required for the medical practice.  Topics include:  managed care, reimbursement, and coding.

Competency Areas

Hours

Managed Care

Class

1

Reimbursement and Coding

D. Lab

2

 

P. Lab/O.B.I.

3

 

Credit

3

 

Prerequisite:

Program Admission, AHS 101, AHS 109, MAS106

 

Corequisite:

MAS 103, MAS 111, MAS 112

 

 

Course Guide

 

Competency

After completing this section, the student will be able to:

Hours

Class

D.Lab

P.Lab/

O.B.I.

MANAGED CARE

2

2

5

Insurance vocabulary

Define frequently used insurance terms and abbreviations.

 

 

 

 

Describe and define a variety of third party reimbursement methods.

 

 

 

Insurance plans

Identify and describe different types of insurance plans, including but not limited to:

Governmental Carriers:  Medicare, Medicaid, TRICARE, etc.

Managed Care: HMO, PPO, POS 

Workers’ Compensation

Blue Cross Blue Shield

Private insurance

 

 

 

 

Cite advantages of group vs. private health insurance.

 

 

 

Federal regulations

Describes medical necessity and proper documentation required for proper reimbursement.

 

 

 

 

Define fraud and abuse.

 

 

 

 

Describe the impact of HIPAA and other government regulations on the reimbursement process.

 

 

 

REIMBURSEMENT AND CODING

8

18

25

Diagnostic coding for insurance forms

Demonstrate use of ICD coding books and CPT coding books.

 

 

 

 

Demonstrate usage of the HCPCS manual.

 

 

 

 

Demonstrate appropriate use of modifiers.

 

 

 

Apply third party guidelines

Complete precertification form.

 

 

 

 

Complete a referral from.

 

 

 

Claims submission

Abstract from patient records to complete insurance claim forms.

 

 

 

 

Identify and complete appropriate CMS 1500 claim forms for patients covered by private, group, or government insurance plans.

 

 

 

 

Describe the process for claims submission.

 

 

 

Claims rejections

List reasons for claims rejection and purpose solutions for rejection.

 

 

 

 

Identify the process for resubmitting a claim.

 

 

 

 

Suggested Resources

 

TEXTS

 

Buck, C.  (2006). The next step: Medical coding from classroom to practice.  St. Louis: Elsevier.

Green, M.  (2008). 3-2-1 code it!. Albany, NY: Thomson Delmar Learning.

Lindh, W.Q., Pooler, M.S., Tamparo, C.D. & Dahl, B.M. (2006). Thomson Delmar Learning's comprehensive medical assisting, administrative and clinical competencies. 3rd ed. Albany, NY: Thomson Delmar Learning.

Lindh, W.Q., Pooler, M.S., Tamparo, C.D. & Dahl, B.M. (2006). Workbook to accompany Thomson Delmar Learning's comprehensive medical assisting, administrative and clinical competencies. 3rd ed. Albany, NY: Thomson Delmar Learning.

Newby, C. (2008). From patient to payment: Insurance procedures for the medical office with CD-ROM & student data  disk. 4th ed.  New York, NY: Glencoe McGraw-Hill.

Rowell, J. C. & Green, M. A. (2006). Understanding health insurance, a guide to billing and reimbursement. Albany, NY: Thomson Delmar Learning.

Valerius, J,  Bayes, N. L, Newby, C., & Seggern, J. I.B. (2006). Medical insurance: An integrated claims process  approach. 3rd ed. New York, NY: Glencoe McGraw-Hill.

 

WEBSITES

 

ECM Paradigm http://www.emcp.com/product_catalog/index.php?GroupID=87

 

Elsevier http://www.elsevier.com/wps/find/simple_search.cws_home?pubtype=Any&boost=true&needs_keyword=true&adv=false&keywords=&action=product_search

 

FA Davis http://www.fadavis.com/health_profession/index.cfm

 

Glencoe/McGraw Hill  http://catalogs.mhhe.com/mhhe/home.do

 

Thomson Delmar Learning http://www.delmarlearning.com/healthcare/Index.aspx?cat1ID=HCR

Prentice Hall http://vig.prenhall.com/

 

 

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