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Hospitals and Other Providers
Business Partners
Physicians and Other Practitioners

Career level:

Experienced Professional
Early Careerist

Recommended for:

Patient Access
Physician Practice
Revenue Cycle

Delivery Method:

Self Study

Advance Preparation:




Course Availability:

18 Months

Fact Sheet | Payment, Reimbursement, and Managed Care
HFMA presents a comprehensive summary of the FY21 IPPS proposed rule, released by CMS.
Fact Sheet | Payment, Reimbursement, and Managed Care
HFMA presents this overview of the CMS FY21 IPPS proposed rule.
Column | Payment, Reimbursement, and Managed Care
The COVID-19 crisis raises important questions for the U.S., including how it should prepare for the inevitable occurence of other potential serious pandemics in the future.
News | Payment, Reimbursement, and Managed Care
Some health plans are accelerating payment processing or offering advances to help stabilize hospitals strained by the effects of the ongoing pandemic.
Fact Sheet | Payment, Reimbursement, and Managed Care
Highlights of interim final rule that, for the duration of the COVID-19 public health emergency (PHE), offers providers flexibility by reinterpreting regulations.
Course | Intermediate | Payment, Reimbursement, and Managed Care

Medicare and Medicaid Reimbursement Systems

Course | Intermediate | Payment, Reimbursement, and Managed Care

Medicare and Medicaid Reimbursement Systems


This course describes the regulatory agencies that have authority over healthcare organizations, including the Centers for Medicare and Medicaid Services. It also explains how Medicare and Medicaid function as payers, and how different kinds of healthcare organizations are reimbursed for services to beneficiaries. The course explains the ways in which Medicare calculates the amount of reimbursement for services provided by physicians and hospitals as well as how payment rates are set for Medicare HMOs. This course also describes a hospital's responsibilities under the Emergency Medical Treatment and Active Labor Act (EMTALA).

Estimated course completion time: 1 hour
After this program, you'll be able to..
  • List and explain the purpose and activities of various healthcare regulatory agencies, including CMS, PRRB, FTC, Joint Commission, PRO, OIG, and USPHS
  • Recognize how the Public Health Service protects and advances the health of the nation
  • Recognize how the Joint Commission's survey program works
  • Differentiate Medicare from Medicaid
  • Recognize how parts A and B of the Medicare insurance plan are funded
  • Recognize the mechanics of Prospective Payment System (PPS) reimbursement and the services covered under the diagnosis related group (DRG) payment
  • Identify the four phases of the process that Medicare uses to determine cost reimbursement to providers
  • Recognize how ambulatory payment classification groups (APCs) are used in the outpatient prospective payment system (PPS)
  • State the reimbursement formula for physician services
  • Recognize the purpose and process of uncompensated care/S10 reporting
  • Recognize how the adjusted average per capita cost (AAPCC) is used to determine payment rates for Medicare enrollees in HMOs
  • State the four steps used to calculate AAPCC rates
  • Identify the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA)

Related Courses | Payment, Reimbursement, and Managed Care

On Demand Webinar | Basic | Coronavirus

How to manage revenue cycle and operational stability throughout a healthcare crisis (Responsive Revenue Cycle Management Virtual Conference On-demand)

The global COVID-19 pandemic has put the U.S. economy in a fragile state, causing a ripple effect down to the healthcare organizations.  Many elements of this crisis are already impacting the revenue cycle, from forcing leaders to expand remote work options to more employees, to managing the surge of patient volumes, while balancing the demands for information, access and care.

In addition, even with proposed adjustments to reimbursement rates for treating COVID-19 patients, provider are financially at risk due to the loss of elective procedures and non-essential routine visits and screenings, which can be a primary source of revenue for many organizations.  While delaying these visits caused short-term access issues.

Listen to this webinar to discuss how health systems and practices can drive strategies before, during and after the peak of a healthcare crisis to optimize revenue cycle operations and financial performance.

Original Live Webinar Date (4/30/20)

On Demand Webinar | Update | Legal and Regulatory Compliance

An Overview of the Office of Inspector General's Work Plan

The current HHS Office of Inspector General (OIG) Work Plan Includes a mix of historical areas of focus and new issues that the OIG will target in the coming year. Effective June 2017, the OIG updates its Work Plan website monthly, adding new initiated items and removing completed items. Provider organizations need to be aware of the OIG's priorities and understand what drives scrutiny in these key areas.

During this webinar, the presenters provide an overview of the Work Plan and key areas of focus for provider organizations, while summarizing key provisions within the plan.

Original Live Webinar Date: 1/16/20

On Demand Webinar | Update | Legal and Regulatory Compliance

2020 Proposed Rule Changes to the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgery Payment System

The ambulatory surgery (ASC) payment system continues to evolve with the proposed changes to the hospital outpatient system (OPPS) for a calendar year 2020. Find out what changes are proposed for implementation on January 1, 2020 for ASCs and hospital outpatient services in the CY2019 final rule. Physician practice managers will want to keep a close watch on the ASC and OPPS developments as more services migrate from one setting to another. Prepare your organization now for the proposed changes.
Topics Include:
  • Proposed 2020 APC groupings
  • Proposed 2020 OPPS changes to drugs, biological, and radiopharmaceuticals
  • Proposed 2020 changes to OPPS for cancer hospitals and partial hospitalization services
  • Proposed 2020 changes to OPPS packaging
  • Proposed 2020 methods to control outpatient volume increases
  • Proposed 2020 changes for ASCs
  • Proposed 2020 changes to hospital outpatient quality requirements
  • Proposed 2020 additional changes to other policy areas

Course | Overview | Finance and Business Strategy

HFMA Business of Health Care (for CME)

Understand how your decisions impact the delivery of quality care with HFMA's Business of Health Care online program.

No matter your role in healthcare, this online program is designed to provide essential context around the business fundamentals of pricing, cost, revenue, payment, and delivery models.

Once you have completed this online program, you will have the knowledge to work more effectively toward the shared goal of improving patient health.

Available online, 24/7, and at no additional cost when you are a member of HFMA.

Course Outline:

The Big Picture
Financial Accounting Concepts
Cost Analysis Principles
Strategic Financial Issues
Managing Financial Resources
Looking to the Future

Assessment information:
The online course is hosted by Healthcare Financial Management Association and the assessment is hosted by Postgraduate Institute for Medicine. Instructions for accessing the assessment are at the end of the online program. The assessment has 75 multiple choice questions and you have 90 minutes to complete it in one sitting. The passing score is 70%.

Title: HFMA Business of Health Care®
Original Release Date: 3/1/2016
Renewal Date: 4/1/2020
Expiration Date: 4/20/2021
You have access to this course for 18 months from purchase date
HFMA Business of Health Care online study materials PIM cost: $399

PIM designated this continuing education activity for 13.5 CME contact hour(s)
Estimated time to complete activity: 14 hours

Click here for the Postgraduate Institute for Medicine details.

For CME/CE questions, contact Postgraduate Institute for Medicine at

For HFMA Business of Health Care for CME examination (through CME University) technical assistance, you may contact