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Hospitals and Other Providers

Career level:

Early Careerist
Experienced Professional

Recommended for:


Delivery Method:

Self Study

Advance Preparation:




Course Availability:

18 Months

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. 
Video | Claims Adjudication
Common mistakes are not using security options to send records and not tracking what data or claims are sent. 
Course | Overview | Claims Adjudication

Compl: Fraudulent Acts and Other Compliance Risks

Course | Overview | Claims Adjudication

Compl: 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

Course | Overview | Denials Management

Denials Mgt: 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

Course | Overview | Compliance

Compl: False Claims Act: Whistle Blower

This course explains the qui tam provisions under the False Claims Act, and the different ways in which a qui tam action may proceed. The course also explains the potential awards available to relators in qui tam actions.

Estimated course completion time: 2 hours

Course | Overview | Billing and Collections

Billing: The 1500 Health Insurance Claim Form

This course explains the purpose of the 08/05 revised version of the 1500 Health Insurance Claim Form and describes how the form should be completed.

Estimated course completion time: 2 hours and 30 minutes

Certification | Intermediate | Revenue Cycle

Certified Revenue Cycle Representative (CRCR)

Get recognized as a valued contributor to your organization's revenue cycle performance when you earn HFMA's Certified Revenue Cycle Representative (CRCR) certification.

It's essential that front line staff have a broad understanding of today's revenue cycle. From reducing denials, to ensuring regulatory compliance, to enhancing the patient experience, it's more critical than ever to connect processes to financial outcomes.

HFMA's CRCR is the only content available that provides a national-level certification for addressing the contemporary patient-centric revenue cycle. Available online, 24/7, this certification, online program, certification maintenance and digital badging related costs are all included in HFMA membership.

"With HFMA and CRCR I was able to enhance my learning experience and use some of that knowledge during my internship to help write some new policies and work on how we communicate with our patients." - Morgan Coker, Revenue Cycle Manager

Course Outline:
Unit 1: Revenue Cycle in Health Care
Unit 2: Pre-Service - Financial Care
Unit 3: Time of Service - Financial Care
Unit 4: Post-Service - Financial Care

Assessment Information:
This online program includes a key concepts guide, the course modules listed above and a certification assessment. The assessment has 75 multiple choice questions and you have 90 minutes to complete it in one sitting. The passing score is 70%. If you do not pass on the first attempt, there is a mandatory 30-day waiting period. You'll have access to the exam summary and the course while you wait for your next attempt. The exam summary will show you how you did on the questions from each unit of the online program.

Estimated course completion time: 10-14 hours