Reimbursement Systems

Masters Degree in Case Management

CSM 700

Breyer State University

Instructor:Deryl E. Gulliford, Ph.D.

SYLLABUS

COURSE OVERVIEW: This course reviews the diverse financial systems within American healthcare, focusing on reimbursement methods and payment systems. Included are insurance plans, government funding systems such as Medicare and Medicaid, and managed care programs such as HMO’s and PPO’s.

TIME FRAME: This is a five-semester hour course. This course is allotted ten weeks of time. You must complete all the requirements for the course successfully by the end of the ten-week period. The first day of week one will begin the day that you register for the course, or the day, which you notify me that your textbook(s) have arrived and you are ready to begin your studies. Please be cognizant of the time frame. It is rare that extensions of tie are permitted, unless the student has good justification. Upon successful completion of this course, you will be awarded five semester hours of credit.

TEXTBOOKS: The following book is required for this course.

Book 1: Understanding Health Insurance: A guide to Bill and Reimbursement. (9th ed.) Rowell, J. & Green, M. Thomson Delmar Learning Publisher. 2008: ISBN 13: 9781418067069
ISBN 10: 1418067067

Supplemental Text: Nursing case management: From essentials to advanced practice application 4th ed. Cohen, E., Cesta, T. Elsevier Mosby 11830 Westline Industrial Drive, St. Louis, Missouri 63146. ISBN # 0-323-02765-2.

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COURSE FORMAT: This course is divided into five units, covering text chapters as follows:

Unit One – Chapters 1-5
Unit Two - Chapters 6-7
Unit Three - Chapter 8-10
Unit Four - Chapter 11-15
Unit Five – 16-17

It is intended for the five units to be completed in ten weeks time.

EVALUTION: There is a written essay examination for each Unit, and a Scholarly Paper (approximately 10 pages in length, double-spaced) is also required for completion of the course. The Scholarly Paper topic and outline must be approved prior to the writing.

Completion of the first three Unit Exams constitutes midterm progress, and completion of the final two Unit Exams and the Scholarly Paper constitutes final progress. There is no final examination for this course.

GRADING SCALE: You will receive a letter grade based on your overall achievement. The grading scale is as follows:

90–100%    = A
80–89%      = B
70–79%      = C
Below 70%  = Fail

Grade Weighting: Each Unit Exam is worth 15% of the course grade, and the Scholarly Paper is worth 25% of the course grade.

COMMUNICATION: Students are expected to communicate with the professor weekly during the course term. A brief email update is sufficient, although the professor will be pleased to discuss any matter by phone during the work day or during the evening hours at home.

ABOUT YOUR INSTRUCTOR: Dr. Gulliford is CEO of the Northwest Oklahoma Healthcare Consortium, based in Enid, Oklahoma. He has 20+ years of experience in senior healthcare management. His clinical background includes work in respiratory care, critical care, non-invasive and invasive cardiology, and perfusion. Dr. Gulliford is currently National Chairman of the AAMA Small and Rural Healthcare Section and State Director of AAMA for Oklahoma.

Dr. Gulliford's Philosophy: therefore however you want other people to treat you, so treat them.

COURSE OBJECTIVES: Upon completion of this course, you will be able to:

1). Understand the diversity of health reimbursement plans and their characteristics.
2). Identify methods needed to file claims successfully under the various health plans.
3). Descibe methods of coding, RVW, modifiers, and how to legitimately maximize reimbursement.
4). Understand ICD-9-CM and HCPCS.
5). Understand APGS and their impact on payment.
6). Understand DRG’s and their impact on payment.
7). Define and describe clinical risk groups.   

INFORMATION: If you have any questions regarding this program, you may contact admassistant@breyerstate.com

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