Delaware County Community College, Serving Delaware and Chester Counties

AHM 241 - Revenue Cycle Management and Reimbursement Methodologies

Course Description

This course is designed for students to learn the general principles of revenue cycle management and reimbursement methodologies. Students will learn how to complete and use insurance claim forms and insurance related forms (referrals, pre-authorizations, registration forms). The class will provide students with hands-on experiences with a variety of insurance related issues as well as compliance strategies and reporting. Reimbursement systems including fee-for-service payments and capitation payments will be covered in detail as well as regulatory guidelines, management of denials of claims and chargemaster maintenance.

During this course students will have the opportunity to complete an exam offered through the American Medical Billing Association (AMBA). Students who successfully pass the exam will earn the Certified Medical Reimbursement Specialist (CMRS) credential.

Upon successful completion of this course, students should be able to:
Describe legal and ethical issues involved in revenue cycle management and compliance and identifying potential abuse and fraudulent trends through data analysis.
Describe and explain different types of health insurance carriers and reimbursement systems as well as rules and regulations for each (private insurance, managed care, Medicare, Medicaid, Workers Compensation, Military insurance).
Recognize the economic and ethical implications of coding assignment on reimbursement, and how these are impacted by reimbursement systems such as APC's (Ambulatory Payment Classifications, ASC's (Ambulatory Surgery Center) and RBRVS (Resource Based Relative Value Scale).
Accurately complete referral, preauthorization, registration and encounter forms.
Submit claims in paper and electronic format.
Document billing information using correct medical terminology and perform an internal and external chart audit.
Accurately complete referral, preauthorization, registration forms, encounter forms, EOB (explanation of benefits review and analysis) and ABN forms (Advanced Beneficiary Notices). and ensure appropriate coding as per CMS (Center for Medicare and Medicaid Guidelines).
Resolve claim errors and learn how to resubmit claims that have been rejected.
Generate patient bills when needed through interpretation of explanations of benefits/remittance advice statements.
Describe the process of how to follow up with insurance companies and patients regarding unpaid bills.
Record changes, payments and adjustments for patient scenarios provided.

Credit Hours: 3
Lecture Hours: 3

Course Prerequisites: AHM 230 or (AHM 131 and AHM 239)