Professional Development

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Financial Decision-Making in a Healthcare Organization

Course Description

The health care industry is a large, intricate industry that is unlike any other industry. This course attempts to expose and educate students to the financial aspect of health care. Although access to the clinical piece is critical to patients, the financial portion is what achieves its sustainability. For example, "How a provider gets paid" is an important concept to understand when working in the health care industry. Consequently, future and current health care employees will gain an understanding and appreciation of the major areas of financial decision making that health care executives deal with on a daily basis.

Learning Objectives

  • Increase your knowledge of the Medicare payment system, the role of pricing, coding, and billing
  • Learn the factors that influence the financial viability of different health care organizations
  • Understand the financial implications of critical legal and regulatory restrictions
  • Incorporate new management practices to enhance the financial strength of your organization

Course Outline

Corporate Finance in the Health Care Industry

  • Describe the importance of financial information in health care organizations.
  • Discuss the users and uses of financial information.
  • Describe the financial functions within an organization.
  • Discuss the common ownership forms of health care organizations, along with their advantages and disadvantages.

Billing and Coding for Health Services

  • Describe the revenue cycle for health care firms.
  • Understand the role of coding information in health care organizations in claim generation.
  • Define the two major bill types used in health care firms.
  • Define the basic characteristics of charge masters.

Finance Environment of Health Care Organizations

  • Learn the factors that influence the financial viability of a health care organization;
  • Discuss the major reimbursement methods that are used in health care;
  • Identify the major aspects of Medicare benefits and how reimbursement is made
  • Understand the implications of these methods for an organization's resource management.

Legal and Regulatory Environment

  • Explain the financial risks associated with the health care legal and regulatory environment.
  • Explain the difference between fraud and abuse.
  • Identify the managerial and organizational implications of various regulations included: the False Claims Act, the Emergency Medical Transfer and Active Labor Act (EMTALA), Health Insurance Portability and Accountability Act (HIPAA), Stark II laws and the safe harbor regulations
  • Explain the major objectives of US antitrust law as applied to the health care industry.

Revenue Determination

  • Define basic methods of payment for health care firms
  • Understand the general factors that influence pricing
  • Define the basic health care pricing formula and factors that influence it
  • Describe methods that are used to establish prices in a real setting
  • List some of the important considerations when negotiating a managed-care contract

Managed Care

  • Define the different types of health maintenance organizations (HMO)
  • Describe the four main activities of health plans
  • Understand the forces that influenced the development of integrated delivery systems
  • Learn the methods by which providers are paid in a managed-care environment
  • Discuss legal and regulatory issues that affect MCOs


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