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Hospitals and Other Providers
Business Partners
Health Plans
Physicians and Other Practitioners

Career level:

Experienced Professional

Recommended for:

Client Services
Patient Access
Patient Accounts
Patient Financial Services
Revenue Cycle

Delivery Method:

Self Study

Advance Preparation:




Course Availability:

18 Months

Article | Claims Adjudication
A leading claims management company talks about how it streamlines the complex billing and follow-up activities associated with motor vehicle and workers’ compensation accident claims, driving revenue into healthcare organizations.
How To | Claims Adjudication
The University of Rochester Medical Center’s high-cost drug manager works to help patients get access to appropriate drugs and mitigates the financial risk associated with buying and administering them.
Case Study | Claims Adjudication
UnitedHealthcare’s new policy of auditing certain emergency department claims should prompt hospitals to seek the expertise of clinical documentation improvement teams in outpatient claim processing. 
Case Study | Claims Adjudication
Boston Medical Center has achieved average cycle times of 90 and 120 days respectively for workers’ compensation and motor vehicle accident claims.
Blog | Claims Adjudication
George Abatjoglou explains the importance of knowing how to process a common, but often mishandled, type of claim. 
Course | Intermediate | Claims Adjudication

Fraudulent Acts and Other Compliance Risks

Course | Intermediate | Claims Adjudication

Fraudulent Acts and Other Compliance Risks


This course defines fraud and abuse as it relates to Medicare and Medicaid. It explains the components of an effective compliance program and describes violations of False Claims regulations and associated penalties. This course explains the key provisions of the Health Insurance Portability and Accountability Act (HIPAA). It explains how a healthcare organization qualifies for tax-exempt status and how such an organization may generate unrelated business income that may be taxable.

Estimated course completion time: 30 minutes
After this program, you'll be able to..
  • Identify situations that would be classified as fraud or abuse under the Social Security Act and other legislation
  • Name the most common forms of fraud related to Medicare
  • Recognize the circumstances under which civil monetary penalties (CMP) are imposed
  • List elements that should be included in a compliance program for conformance to the False Claims Act
  • Identify OIG regulations relating to kickbacks, bribes, and rebates
  • List the payment or business practices covered by safe harbors
  • Recognize the HIPAA requirements for standard transactions
  • Recognize the HIPAA requirements for code sets
  • Recognize how a healthcare organization qualifies for tax-exempt status
  • State examples of activities that do and do not generate unrelated business income
  • Identify how to compute unrelated trade or business taxable income
  • Recognize the types of transactions that may create excess benefit for individuals affiliated with tax-exempt organizations
  • Recognize the need for reporting and the costs that are typically included in community benefits
  • Differentiate between uncompensated and charity care

Related Courses | Claims Adjudication

On Demand Webinar | Overview | Coronavirus

COVID-19 Addressing financial and operational impacts to providers

The impact of COVID-19 on the healthcare industry has been broad and significant. This webinar explores eight potential scenarios and offers recommendations on how providers can respond to the operational and financial challenges caused by this pandemic.

Learn how issues-such as unemployment, emergency department surge, newly uninsured and non-traditional visits, staffing constraints and others can directly impact your bottom line.  Strategies will be shared that you can put in place today to help ensure positive clinical and financial outcomes.

Original Live Webinar Date: (4/28/20)

Course | Overview | Health Plan Payment and Reimbursement

Health Plans - An Overview

In this course we will address the basic billing rules for major health plans, including an overview of basic billing features and benefits, types of billing rules and minor claim payers and plans.

Estimated course completion time: 30 minutes

Course | Intermediate | Contracting

Managed Care Contracting and Negotiating

This course discusses criteria to use in evaluating the written contract between the provider and managed care organization, which defines the rights and obligations of the parties under the health plan/provider relationship. It also defines key contract terminology, provisions, and clauses and describes reimbursement levels and methodologies. It highlights general issues that commonly arise during the contract negotiation process and describes common negotiation strategies. It defines direct contracting and third-party contracting and points out the differences between them.

Estimated course completion time: 1 hour

Course | Intermediate | Denials Management

Successfully Appealing Denials

This course explains how improving management of the claims denial process can have a positive effect on a hospital's bottom line. It presents best practices that will help to capture a significantly higher proportion of claims and increase collections, including steps and strategies for successful appeals.

Estimated course completion time: 3 hours