MAP 120 - Medical Office Management II

1. Gain understanding of Health Insurance and the relationships between Patients, Providers and Insurance Companies/Third-Party Payers.
2. Understand how to translate the medical exam/medical record into procedural and diagnostic codes.
3. Understand the process involved in billing services for patients to insurance companies and obtaining reimbursement.
4. Handling patient accounts and understanding the flow of funds through the practice.
5. Understand banking procedures for the business.
6. Learn strategies for creating a positive work environment and a motivated team atmosphere.
7. Develop tools and skills for finding and retaining employment.

Course Objectives:

Unit 1: Health Insurance Essentials

1. Discuss the purpose of health insurance and discuss the concept of cost sharing.
2. List and discuss various government-sponsored plans.
3. Summarize private health insurance plans.
4. Review traditional (fee-for-service) health insurance plans.
5. Differentiate among the different types of managed care models.
6. Identify managed care requirements for patient referral
7. Identify types of third-party plans
8. Identify processes for: a. verification of eligibility for services; b. precertification/preauthorization; c. tracking unpaid claims; d. claim denials and appeals
9. Discuss participating provider contracts, including contracted fee schedules.
10. Interpret information on an insurance card
11. Verify eligibility for services
12. Describe other types of insurance, including disability, life, long-term care and liability insurance.
13. Obtain precertification or preauthorization including documentation
14. Define the following: a) bundling and unbundling of codes; b) advanced beneficiary notice (ABN); c) allowed amount; d) deductible; e) co-insurance; f) co-insurance

Unit 2: Diagnostic Coding Essentials

1. Describe the historical use of the International Classification of Disease (ICD) in the United States and describe how diagnostic coding is related to medical necessity
2. Identify the structure and format of the ICD-10-CM.
3. Describe how to use the Alphabetic Index to select main terms, essential modifiers, and the appropriate code (or codes) and code ranges.
4. Explain how to use the Tabular List to select main terms, essential modifiers, and the appropriate code (or codes) and code ranges.
5. Summarize coding conventions as defined in the ICD-10-CM coding manual.
6. Review the official coding guidelines to assign the most accurate ICD-10-CM diagnostic code
7. Explain how to abstract the diagnostic statement from a patient’s health record.
8. Identify the current procedural and diagnostic coding systems, including Healthcare Common Procedure Coding Systems II (HCPCS Level II)
9. Perform diagnostic coding
10. Identify how encoder software can help the coder assign the most accurate diagnostic codes.
11. Explain the importance of coding guidelines for accuracy, discuss special rules and considerations that apply to the code selection process, and maximize third-party reimbursement.
12. Review medical coding and ethical standards

Unit 3: Procedural Coding Essentials

1. List and describe the three code categories in the CPT manual.
2. Distinguish between the Alphabetic Index and the Tabular List in the CPT code set.  Also list the six different sections of the tabular list.
3. Discuss special reports, and explain the importance of modifiers in assigning CPT codes.
4. Review various conventions in the CPT code set.
5. Identify the required medical documentation for accurate procedural coding.
6. Describe the steps that should be taken in order to be efficient with CPT procedural coding. Also discuss how to use the Alphabetic Index and the Tabular List.
7. Identify CPT coding guidelines for Evaluation & Management (E/M) procedures. 
8. Perform procedural coding
9. Identify CPT coding guidelines for anesthesia procedures.
10. Identify CPT coding guidelines for surgery procedures.
11. Discuss coding factors for the integumentary system and muscular system, and for maternity care and delivery.
12. Identify CPT coding procedure for Radiology, Pathology, Laboratory and Medicine sections.
13. Identify the current procedural and diagnostic coding systems, including Healthcare Common Procedure Coding Systems II (HCPCS Level II)
14. Identify the effects of a.) upcoding, b.) downcoding
15. Identify procedures and services that require HCPCS codes.
16. Summarize common HCPCS coding guidelines.
17. Utilize tactful communication skills with medical providers to ensure accurate code selection

Unit 4: Medical Billing and Reimbursement Essentials

1. Describe the medical billing process, identify types of information contained in the patient’s billing record, and interpret information on an insurance card
2. Discuss managed care policies and procedures, including precertification/preauthorization and referrals, and show sensitivity when communicating with patients regarding third party requirements
3. Identify: a. types of third party plans; b. steps for filing a third party claim
4. Explain how to submit health insurance claims, including electronic claims, to various third-party payers.
5. Complete an insurance claim form
6. Identify fraud and abuse as they relate to third party reimbursement
7. Discuss methods of preventing the rejection of claims.
8. Display tactful behavior when communicating with medical providers regarding third party requirements
9. Describe ways of checking a claim’s status.
10. Identify the purpose and components of the Explanation of Benefits (EOB) and Remittance Advice (RA) statements
11. Discuss reasons for denied claims.
12. Define medical necessity
13. Utilize medical necessity guidelines
14. Apply managed care policies and procedures and describe the process for precertification.
15. Obtain precertification or preauthorization including documentation
16. Identify patient financial obligations for services rendered
17. Inform a patient of financial obligations for services rendered
18.  Demonstrate professionalism when discussing patient’s billing record
19. Assist a patient in understanding an Explanation of Benefits (EOB)

Unit 5: Patient Accounts and Practice Management

1. Define the following bookkeeping terms: a. charges; b. payments; c. accounts receivable; d. accounts payable; e. adjustments; f. end of day reconciliation
2. Perform accounts receivable procedures to patient accounts including posting: a. charges; b. payments; c. adjustments  
3. Also, discuss payment at the time of service and display sensitivity when requesting payment for services rendered
4. Describe the impact of the Truth in Lending Act on collections policies for patient accounts.
5. Describe successful collection techniques for patient accounts.
6. Describe types of adjustments made to patient accounts including: a. non-sufficient funds (NSF) check; b. collection agency transaction; c. credit balance; d. third party
7. Explain the purpose of the Federal Reserve Bank and the types of banks it manages.
8. Identify common types of bank accounts.
9. Discuss the importance of signature cards.
10. Explain how online banking has made standard banking process more efficient.
11. Compare different types of negotiable instruments.
12. Identify precautions for accepting the following types of payments: a. cash; b. check; c. credit card; d. debit card
13. Review the procedure followed when the healthcare facility receives a nonsufficient funds (NSF) check.
14. Describe banking procedures as related to the ambulatory care setting
15. Explain the importance of depositing checks daily.
16. Prepare a bank deposit
17. Compare types of check endorsements.
18. Understand the purpose of bank account reconciliation for auditing purposes, and how to pay bills in order to maximize cash flow.

Unit 6: Advanced Roles in Administration

1. Define the qualities and responsibilities of a successful office manager in a healthcare facility.
2. Explain how to conduct a staff meeting with an agenda.
3. Identify several ways in which employees are motivated.
4. Discuss strategies to create a team environment in the healthcare facility.
5. Identify communication barriers
6. Identify the need to find the right employee for an opening in the medical office.
7. Review a general job description for medical assistants.
8. Explain how to search through résumés and applications for potential candidates.
9. Identify legal and illegal applicant interview questions
10. Explain how to select the most qualified candidates.
11. Identify follow-up activities the office manager should perform after an interview.
12. Review new employee orientation, including paperwork, training and development.
13. Discuss strategies for determining fair salaries and raises, addressing a problem employee and terminating an employee.
14. Identify information that should be included in a personnel policy manual.
15. Describe how office policies are different from personnel policies.

Unit 7: Skills and Strategies

1. Describe personality traits important to employers.
2. Discuss personality traits, technical skills and transferable job skills.
3. Discuss career objectives and describe how personal needs affect the job search.
4. Create a résumé and cover letter.
5. Practice interview skills for a mock interview.
6. Identify legal and illegal applicant interview questions
7. Explain common human resource hiring requirements when starting a new job.