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HIM 2165 Healthcare Data in Reimbursement

Organization of health care delivery system including managed care and capitation. Theory and use of reimbursement systems such as Diagnostic Related Groups, Ambulatory Payment Classifications, Resource-based Relative Value Scale. Discussion of data flow from admission to billing and analysis of casemix. In addition, other external forces, such as Health Insurance Portability and Accountability Act and Recovery Audit Contractors, will be discussed. Two classroom, two lab hours per week.

Division: Health Sciences
Department: Health Information Management
Repeatable Credit: No
Offered Online: Yes

Prereqs: HIM 1110 AND HIM 1201 


  • Define health care reimbursement terms, phrases, and abbreviations.
  • Examine coding compliance issues that influence reimbursement.
  • Differentiate between the code sets approved by the HIPAA of 1996.
  • Differentiate between the various government-sponsored healthcare programs.
  • Explain the common models and policies of payment for inpatient and outpatient Medicare and Medicaid prospective payment systems.
  • Apply DRG, MS-DRG, APC-based, (etc.) reimbursement principles and payment rate calculations.
  • Explain the major types of voluntary healthcare insurance plans and the common models and policies of payment for commercial healthcare plans.
  • Describe the selection and development of applications and processes for organizations' revenue cycle management including chargemaster, claims management and financial decision support.
  • Manage the use of clinical data required in prospective payment systems (PPS) and other reimbursement systems in healthcare delivery.
  • Describe the origin, evolution and types of managed care plans as they relate to healthcare reimbursement.
  • Describe the flow of clinical and financial data from registration through account resolution in a variety of healthcare settings.
  • Demonstrate the ability to correctly utilize encoders, diagnosis-related reimbursement and casemix analysis.
  • Demonstrate the personal behaviors, attitudes, and values consistent with and appropriate to the entry-level HIM professional.
  • Describe the similarities and differences between the major payment methods in the US including Inpatient and Outpatient Prospective Payment systems plus the organization of various healthcare reimbursement systems including managed care, resource-based relative value scale and describe the impact of clinical data on reimbursement.

Credit Hours: 3

Classroom Hours: 2
Lab Hours: 2