MAST 1100 Syllabus

Subject Code

MAST

Course Number

1100

Course Title

Medical Insurance Management

Prerequisites

Program admission

Corequisites

BUSN 1100, MAST 1060

Terms Offered

Offered Fall and Spring

Credit Hours

(1-3-2)

Course Description

This course emphasizes the essential skills required for the medical practice. Topics include managed care, reimbursement, and coding.

Course Outcomes

Managed Care

 

  • Define frequently used insurance terms and abbreviations.
  • Identify types of insurance plans.
  • Describe these types of insurance plans, Governmental Carriers; Medicare; Medicaid; TRICARE, etc; Managed Care: HMO, PPO, POS; Worker’s Compensation; Blue Cross Blue Shield; and private insurance.
  • Identify models of managed care.
  • Discuss Worker’s Compensation as it applies to patients.
  • Cite advantages of group vs. private health insurance.
  • Describe procedures for implementing both managed care and insurance plans.
  • Describe medical necessity and proper documentation required for proper reimbursement.
  • Discuss utilization review principles.
  • Discuss referral process for patients in a managed care program.
  • Describe how guidelines are used in processing an insurance claim.
  • Compare processes for filling insurance claims both manually and electronically.
  • Describe guideline for third party claims.
  • Discuss types of physician fee schedules.
  • Describe the concept of RBRVS.
  • Define Diagnosis-Related Groups (DRGs).
  • Apply both managed care policies and procedures.
  • Apply third-party guidelines.
  • Demonstrate completion of insurance claim forms.
  • Demonstrate obtaining precertification, including documentation.
  • Demonstrate obtaining preauthorization, including documentation.
  • Demonstrate verifying eligibility for managed care services.
  • Display assertive communication with managed care and/or insurance provider.
  • Display sensitivity in communicating with both providers and patients.
  • Display communication in language thee patient can understand regarding managed care and insurance plans.
  • Cooperate with physician to achieve the maximum reimbursement.
  • Discuss insurance fraud and abuse.
  • Describe the impact of HIPAA and other government regulations on the reimbursement process.

 

Reimbursement and Coding

 

  • Describe how to use the most current procedural coding system.
  • Define upcoding and why it should be avoided.
  • Describe how to use the most current diagnostic coding classification system.
  • Demonstrate use of ICD coding books and CPT coding books.
  • Demonstrate appropriate use of modifiers.
  • Describe how to use the most current HCPCS.
  • Perform procedural coding.
  • Perform diagnostic coding.
  • Demonstrate completion of a referral form