Healthcare Careers 3 of 3 (Option A): Insurance, Billing and Coding Essentials (Certification Prep HI-1015N)

About This Course

MedCerts HI-1015N is the capstone course 3 of 3 in an online healthcare careers industry certification prep program. HI-1015N is the final course in the HI-1100 Medical Billing Specialist program for the target certification: Certified Billing and Coding Specialist (CBCS) from the National Healthcareer Association (NHA). To achieve a certification, students must successfully complete all three required courses, earn a high school diploma or GED within the next 12 months, create an account on the NHA Certification Portal, and register to complete the CBCS national certification exam either at your school, a PSI testing center near you, or through live remote proctoring at the location of your choice.
Insurance and Billing, and Coding Essentials is a comprehensive course with insight and focus on the role of the Insurance Billing Specialist. The course provides foundational knowledge required of an administrative allied healthcare professional. Emphasis is placed on the revenue cycle and basic insurance terminology. This includes topics related to HIPAA and HITECH laws and regulations, patient financial responsibility, insurance verification, government and commercial insurance plans, diagnosis coding using ICD-10-CM, procedure coding using CPT and HCPCS, modifiers, and the encounter form. CMS-1500 and HIPAA 837P claim formats, payment processing, claim follow up, and collections.
In this course, students are exposed to a variety of eLearning elements that allow hands-on interaction with the screen for an engaging education. In addition to video-based instruction that provides foundational knowledge, a variety of other learning methods are utilized for engagement, entertainment, and inspiration throughout training. These may include interactive skill activities, game-based learning, an immersive environment for critical thinking skills, and hands-on interaction. Prerequisites:  Completion of high school biology and chemistry coursework, as well as Medcerts courses PS-1011N, and HI-1014N

Course Objectives: Upon completion of this course, students will be able to...

• Describe the phases of the revenue cycle and gain an understanding of basic insurance terminology
• Describe healthcare opportunities and certification for the insurance specialist
• Discuss some different managed care plans
• List various healthcare benefits and insurance plans
• Define the different phases of the revenue cycle and related tasks
• Demonstrate knowledge of confidentiality and billing laws, regulations, and standards
• Identify laws and regulations that apply to the insurance specialist
• Describe use of the electronic health record and types of documentation
• Distinguish the similarities and differences of HIPAA and HITECH
• Define protected health information
• Explain the role of the Office of Inspector General
• Define written, informed, and implied consents
• Determine what constitutes fraud and abuse
• Explain verification of patient financial responsibility and insurance information
• Recognize the difference between new and established patients
• Explain the collection of insurance data, verification, and eligibility
• Determine information necessary to establish financial responsibility
• Discuss eligibility, in-network and out-of-network coverage, preauthorization, and predetermination
• Describe the dependent, gender, and birthday rules
• Define assignment of benefits, time-of-service payments, and advance beneficiary notice
• Differentiate government and commercial insurance plans and determine which is primary
• Apply ICD-10-CM, CPT, and HCPCS codes and modifiers based on coding guidelines
• Explain the purpose and use of the ICD-10-CM manual, alphabetic index, and tabular list
• Discuss the organizations responsible for publishing and updating the ICD-10-CM code set
• Identify the difference between main terms, subterms, and nonessential modifiers in the ICD-10-CM alphabetic index
• Define chapter structure, categories, and subcategories in the ICD-10-CM tabular list
• Apply introductory diagnosis coding skills
• Identify the conventions in the ICD-10-CM alphabetic index
• Discuss the impact of instructional notations with diagnosis coding
• Explain General Evidence Mapping (GEM)
• Describe the six steps to assign a diagnosis code and the impact of coding guidelines
• Assign and sequence diagnosis codes correctly based on abstraction of data
• Explain the purpose and use of the CPT manual guidelines, index, and sections
• Discuss the organization responsible for publishing and updating the CPT code set
• Identify the difference between main terms and modifying terms in the CPT index
• Define CPT format, symbols, and modifiers
• List the main sections of the CPT manual
• Describe the steps to assign a procedure code
• Apply introductory procedure coding skills
• Explain the purpose and use of the HCPCS manual
• Discuss the organization responsible for publishing and updating the HCPCS code set
• Describe the steps taken to assign a HCPCS code
• Compare and contrast CPT and HCPCS codes
• Apply Introductory HCPCS coding skills
• Identify billing compliance errors with coding, code linkage, medical necessity, and the revenue cycle
• Identify strategies for successful billing compliance including use of payer coding screens
• Describe internal and external auditing requirements
• Differentiate provider and payer fee schedules
• Explain payment systems including RBRVS, fee-based, contracted, capitation, and time-of-service
• Explain the difference between CMS-1500, HIPAA 837P, UB-04/CMS-1450, and HIPAA X12 837I claims
• Complete CMS-1500 claim blocks and discuss claim submission
• Detail completion of the HIPAA 837-P claim and electronic data interchange
• Describe the use of a clearinghouse versus direct transmission of healthcare claims
• Identify the use of the UB-04/CMS-1450 claim and the code sets utilized for institutional billing
• Differentiate between group, private, and commercial healthcare insurance plans
• Compare and contrast preauthorization and precertification
• Explain point-of-service, indemnity, medical home, and consumer driven private payer options
• Discuss the Patient Protection and Affordable Care Act (PPACA)
• Transmit HIPAA 837P electronic claims accurately and successfully
• Describe the parts of Medicare, eligibility, coverage, and benefits
• Explain the differences between Medicare participating and nonparticipating providers
• Discuss the various Medicare plans including original, advantage, fee-for-service, and Medigap
• Define Program Integrity Contractor
• Transmit electronic Medicare claims accurately and successfully
• Identify the components of the Medicare Summary Notice (MSN)
• Describe Medicaid eligibility, coverage, and benefits
• Discuss covered and noncovered services for the Medicaid recipient
• Define Federal and State Medicaid Programs
• Explain the Medicaid Integrity Program
• Distinguish the claim submission process versus the claim follow-up process
• Transmit electronic Medicaid claims accurately and successfully
• Describe the TRICARE program and eligibility
• Identify the types of TRICARE coverages
• Discuss the CHAMPVA program and eligibility
• Identify covered services for TRICARE and CHAMPVA and DEERS user
• Explain the claims process for TRICARE and CHAMPVA
• Transmit electronic claims accurately and successfully
• Differentiate the Federal and State roles in Worker’s Compensation
• Discuss eligibility for Worker’s Compensation and documentation requirements
• Explain Worker’s Compensation billing and claim management
• Describe Disability, Automotive, and Homeowner’s plans and requirements
• Transmit electronic claims accurately and successfully, applying the correct filing order
• Identify and discuss the five steps in the claim adjudication process
• Identify approaches used to manage claim status
• Recognize that aging reports are used to determine the necessity for payer inquiries
• Explain the remittance advice, adjustment codes, takebacks, and withholds
• Describe posting and applying payments and when to use the appeal or grievance process
• Discuss Medicare, TRICARE, and Medicare/Medicaid crossover and secondary claims
• Determine financial responsibility and define guarantor
• Explain patient statements and the billing cycle
• Discuss collection procedures including regulations, credit and payment laws, and payment plans
• Describe when to use collection agencies and credit reporting requirements
• Differentiate posting payments, account write-offs, and bad debts

Course Outline:

Lesson 1 – The Insurance Specialist and Revenue Cycle

Lesson 2 – Using and Protecting Health Information

Lesson 3 – The Patient Encounter

Lesson 4 – An Overview of the ICD-10-CM

Lesson 5 – Instructional Notations of the ICD-10-CM

Lesson 6 – Introduction to CPT

Lesson 7 – Introduction to HCPCS

Lesson 8 – Encounter Charges and Billing

Lesson 9 – The Healthcare Insurance Claim

Lesson 10 – Private and ACA Health Insurance

Lesson 11 – Medicare

Lesson 12 – Medicaid

Lesson 13 – TRICARE and CHAMPVA

Lesson 14 – Other Compensation Plans

Lesson 15 – Health Insurance Claim Follow-up

Lesson 16 – Billing and Collections

Resources Included: This course includes additional learning resources provided as a supplement to the core training components. Students are required to complete several of these supplements within the course. These may include interactive elements, simulations, and game-based learning. Some supplements, such as a course textbook or ebook, may reference additional activities or assignments as well. While students are not required to submit these additional activities, MedCerts strongly encourages students to utilize these resources to allow for a more comprehensive learning experience, increase the likelihood of subject matter retention, and better prepare for certification success.
MedCerts’ highly immersive courses utilize up to 12 unique eLearning components designed to keep students engaged, stimulated, and entertained throughout their training. The eLearning Components in the course may include instructor-led video lecture, animations, demonstrations, simulations, 3D interactive training environments, games, activities, assessments, and more. These activities are designed to translate into critical skill-building and preparation for a new career. This multi-sensory delivery method provides students with a solid foundation for their overall education.
This course includes the following instructional content: Medical Insurance, A Revenue Cycle Process Approach (McGraw-Hill 9th Edition SMARTBOOK, Copyright 2024 by Valerius, Bayes, Newby, and Blochowiak); Insurance and Billing, and Coding Essentials (MedCerts)--Recorded Video-Based Lecture/Instruction; Introduction to Human Anatomy & Medical Terminology (MedCerts)--Recorded Video-Based Lecture/Instruction; Insurance and Billing, and Coding Essentials (MedCerts)--Skill Presentations and Knowledge Checks; Insurance and Billing, and Coding Essentials (MedCerts)--Critical Thinking Interactivity; Insurance Billing Simulation Training (EHRClinic McGraw-Hill)--Electronic Completion of Medical Insurance Claims; and Medical Insurance, A Revenue Cycle Process Approach (McGraw-Hill)--Adaptive Learning Questions.

Additional Costs: None

Scoring System: Michigan Virtual does not assign letter grades, grant credit for courses, nor issue diplomas. A final score out of total points earned will be submitted to your school mentor for conversion to their own letter grading system.

Time Commitment: Semester sessions are 18-weeks long: Students must be able to spend 1 or more hours per day in the course to be successful. This course requires 6 to 7 hours weekly to complete within a typical semester term.

Technology Requirements: Students will require a computer device with headphones, a microphone, webcam, up-to-date Chrome Web Browser, and access to YouTube. MedCerts programs require a PC, Mac, or Chromebook device, with a standard high-speed internet connection. Google Chrome is the preferred browser for training. Please note, while some activities may work on a mobile device or tablet, MedCerts programs are not designed to be used on these devices. Mobile devices and tablets are therefore not considered supported devices.

Ensure that your school or district network and device administrator establishes network access permissions or exceptions for online resources relevant to the course in which you are choosing to enroll. Ref., Michigan Virtual Course Allow List

Please review the Michigan Virtual Technology Requirements.

Instructor Support System: For technical issues within your course, contact the Customer Care Center by email at CustomerCare@michiganvirtual.org or by phone at (888) 889-2840.

Instructor Contact Expectations: Students can use email or the private message system within the Student Learning Portal to access highly qualified teachers when they need instructor assistance. Students will also receive feedback on their work inside the learning management system. The Instructor Info area of their course may describe additional communication options.

Academic Support Available: In addition to access to a highly qualified, Michigan certified teacher, students have access to academic videos and outside resources verified by Michigan Virtual. For technical issues within the course, students can contact the Michigan Virtual Customer Care by email at customercare@michiganvirtual.org or by phone at (888) 889-2840.

Required Assessment: This MedCerts course is considered PASS/FAIL. Throughout the course, various quizzes, assessments, or activities will require a minimum passing score to proceed in the course. Scores for these elements are available immediately, and these elements may be attempted until a satisfactory score is achieved. This course may also contain additional, nongraded assessments, such as games, simulations, and interactive activities, that must be successfully completed to progress through the course.
Grades for quizzes and exams are available immediately after completion of the quiz or exam. Quizzes and exams are considered Pass/Fail, with a minimum score of 100% required for eBook lesson quizzes and 80% required for CBCS Knowledge Assessment exams. Each may be retaken until a satisfactory score is achieved. Students may retake quizzes/exams an unlimited number of times. This model ensures that the student is more easily able to identify difficult/challenging areas where improvement may be needed, refocus efforts on these areas, and reassess for mastery of content. Students must complete the 52 eBook/lesson quizzes and 4 CBCS Knowledge Assessments.

Technical Skills Needed: Basic technology skills necessary to locate and share information and files as well as interact with others in a Learning Management System (LMS), include the ability to:

• Download, edit, save, convert, and upload files
• Download and install software
• Use a messaging service similar to email
• Communicate with others in online discussion or message boards, following basic rules of netiquette
• Open attachments shared in messages
• Create, save, and submit files in commonly used word processing program formats and as a PDF
• Edit file share settings in cloud-based applications, such as Google Docs, Sheets, or Slides
• Save a file as a .pdf
• Copy and paste and format text using your mouse, keyboard, or an html editor’s toolbar menu
• Insert images or links into a file or html editor
• Search for information within a document using Ctrl+F or Command+F keyboard shortcuts
• Work in multiple browser windows and tabs simultaneously
• Activate a microphone or webcam on your device, and record and upload or link audio and/or video files
• Use presentation and graphics programs
• Follow an online pacing guide or calendar of due dates
• Use spell-check, citation editors, and tools commonly provided in word processing tool menus
• Create and maintain usernames and passwords

Additional Information: None