The Health Care Claim Life Cycle 101 & Medical Coding 101

Online Courses from the American Health Law Association

The smooth processing of health care claims depends in large part on accurate coding. Disputes relating to claims and coding are a threat to the successful operation of any health care enterprise.

In each of these courses, learners will acquire the basics of health care claims and coding by engaging with clear and concise explanations, coupled with videos in which experienced practitioners elaborate on more challenging concepts.

Designed for early career attorneys, compliance professionals, payment professionals, and advisors new to health care, these courses establish a firm foundation for understanding both effective operations and potential pitfalls related to health care claims and coding.

Every time an individual receives a health care service (e.g., annual check-up, physical therapy, blood test, outpatient surgery, CT scan, emergency care, etc.), the health care provider submits a "claim" to the patient's health insurance plan.

Obtaining reimbursement for health care is a complicated financial process that involves several moving parts, such as reconciling insurance payments, making contractual adjustments, writing off losses and unreceived payments, and determining the amount owed by the patient.

This course explains the many laws and regulations that spell out the rights, responsibilities, and obligations of all parties involved in shepherding a claim from Point A to Point Z.

Course Syllabus

1. The Humble Health Care Claim Has an Entire Life Cycle of Its Own
2. Laws and Other Governing Rules That Regulate the Health Insurance Industry
3. How Does the Provider Get Paid?
4. The Health Care Claim and Its Life Cycle
5. The Pre-Claim Submission Process
6. A Brief Detour into the World of Medical Coding
7. The Pre-Claim Payment Process
8. Payment Determination
9. The Post-Payment Process

Medical coding is the language that providers must use when preparing and submitting health care claims to obtain reimbursement.

Commercial insurers have comprehensive fraud detection systems, while the federal government has a robust multi-agency system of identifying, investigating, and prosecuting providers that submit fraudulent health care claims.

Accurate coding results in a "clean claim," which in turn results in timely and accurate payment to the provider. Alternatively, complex legal disputes may arise between payers and providers when allegations of fraudulent claims are made.

Course Syllabus

1. Medical Coding is a Language
2. Terms of Art: Three Basic and Distinct Concepts
3. Different Types of Medical Codes: Which One Are You Using?
4. CPT Code Modifiers
5. The E/M Code: A Type of CPT Code
6. The Most Common Root Causes of Improper Coding
7. Putting It All Together in a Coding Scenario
8. Where Can I Learn More about Code Sets?