HITS-230: Reimbursement Methodologies

Course Description and Prerequisite
This course focuses on the history, rationale, and methodology of the systems used by third-party payers to determine the reimbursement health care providers will receive.  Reimbursement concepts include fee-for-service, managed care, capitation systems, Diagnosis-Related Groups (DRGs), Resource Based Relative Value Scale, Ambulatory Payment Classifications (APCs), and related concepts. The use of the charge description master (charge master) in reimbursement will be discussed. The importance of compliance with regulations and the related issues of fraud and abuse will be addressed.
Prerequisite: HITS-220 Coding and Classification Systems
Student Centered Learning Outcomes

At the end of this course you will have enough information to help you:

  1. Demonstrate understanding of basic healthcare finance concepts and how health information functions and operations impact these concepts.
  2. Explain the process by which standardized billing forms are compiled and the key components related to health information functions.
  3. Demonstrate different methods used for submitting claims to payers, and the pros and cons of each.
  4. Explain how coding impacts payer editing and claims adjudication and the impact of incorrect coding for patients and providers.
  5. Describe the concepts involved with prospective payment systems.
  6. Apply major terms used in the Managed Care Environment.
  7.  Describe the mechanics of APC, DRG and RBRVS payment schedules used by Medicare.
  8. Plan and organize a billing compliance program in the hospital environment and define he role of quality improvement in this program.
Textbook Requirement
Required Text
Understanding Health Insurance, A Guide to Billing and Reimbursement. Twelfth Edition, Michelle A. Green, MPS, RHIA and JoAnne C. Rowell. Delmar, Cengage Learning. ISBN 9781285737522
Topic Outline


Week #Topics & Homework
Week 1
  • Chapters 1, 2 and 3
  • Lectures 1 and 2
  • Discussions 1 and 2
  • Wk 1 Assignments 1 and 2
Week 2
  • Chapters 4 and 5
  • Lectures 3 and 4
  • Discussions 1 and 2
  • Wk 2 Assignment 1
Week 3
  • Chapters 7, 8 and 9
  • Lecture
  • Discussion 1
  • Coding Activity
  • Wk 3 Assignments 1 and 2
Week 4
  • Chapter 11
  • Lecture
  • Discussions 1 and 2
  • Wk 4 Assignments 1 and 2
Week 5
  • Chapter 12 and 13
  • Lecture
  • Discussion 1
  • Wk 5 Assignments 1 and 2
Week 6
  • Chapter 14 and 15
  • Lecture
  • Discussion 1
  • Wk 6 Assignments 1 and 2
Week 7
  • Chapters 16 and 17
  • Discussion 1
  • Wk 7 Assignments 1 and 2
  • Course Paper Due
Methods of Assessment
Your final grade will be determined based on:
Graded ElementsPercentage
Discussion Forums – Posting to the forum and at least two responses per week.32%
Assignments – Weekly assignments50%
Final Assignment – Week 718%
Extra Credit: Course Evaluation2%

Description of Methods of Assessment

Course Discussion and Participation

Your participation is extremely important to the learning experience for both you and your classmates.

You will have weekly forum discussions. In order to receive credit for Participation, students need to be active and engaged in the discussions each week. It is expected that each week students contribute substantively with at least one original post and respond to the posts of at least two other students.

Discussion Rubric

CriteriaDescription Max Points
Frequency Distributes participation across 3-4 days throughout the week creating a dialogue. 20
Initial Discussion Posting Posts well developed, timely discussions that fully address and develop all aspects of the task. 20
Follow-up Postings Demonstrates timely analysis of others’ posts; extends meaningful discussion by building on previous posts. 20
Content Contributions Posts factually correct, reflective and substantive contributions; advances discussion. 20
Reference & Support Uses references to literature, readings, or personal experience to support comments. 20
  Total Points: 100



You will have weekly assignments throughout the course that will allow you to demonstrate your mastery of the course topic. Assignments will be graded on your level of understanding of the course materials and your timeliness of completion.

Discussions: At the start of each week, new discussions will be opened and past discussion forums will be locked.

Course Paper

A course paper will be due by the end of the day Wednesday of week 7. For this assignment, you will implement a billing compliance program for Lake Champlain Medical Center or its owned physician practices. It is your choice as to which you want to work on. The end of Lesson 7 has web sites with compliance information. The compliance checklist attached this assignment is a template for a hospital. The physician compliance PDF is the federal register that outlines what a doc compliance plan should include. You can use either the APA or MLA format for the paper. The final paper will be approximately 7-8 pages and will include at a minimum the following:

  • Reasons for implementing a Billing Compliance Program
  • Names and titles of Key Personnel affected
    • Do you have to hire or promote someone?
  • Compliance Plan that includes definitions, scope, policy and procedures
  • Timeline for implementation
  • How you would carry out training
    • Who is trained? Is it mandatory? How often?
  • How you would handle enforcement of the policies
    • What disciplinary actions will you take? Warnings, suspensions etc.
  • Your procedure for auditing
  • Internal auditing or third-party? Justify your rationale.

Course Withdrawal Policy

Course Withdrawal Voluntary:

It is the student’s responsibility to officially withdraw from a course. Potential consequences of a student’s failure to do so include a failing grade, reduction in financial aid, and/or academic dismissal from the College.

Course Withdrawal Involuntary:

A student may only be involuntarily withdrawn by the instructor due to a student’s violations of the standard of conduct or for disciplinary problems. In other words, an instructor may not involuntarily withdraw a student for poor academic performance or excessive absences. This policy places the responsibility of course withdraw on the student rather than on the faculty. Any questions about this policy can be directed to the Advising & Registration Center (ARC) at arc@champlain.edu or +1 802-860-2777.

Course summary: