Managed Care Program

IRM's Managed Care (MC) Essentials includes five courses: Introduction to Standard MC Reimbursement Methods, MC Payment Review Process, Denials vs. Payment Variance, Medicare Secondary Payer, and Silent Preferred Provider Organizations.

• Introduction to Standard MC Reimbursement Methods provides a better understanding of the various types of reimbursement methodologies. Understanding reimbursement methods will ensure the provider receives accurate and correct reimbursement for services rendered. The purpose of the managed care division is to review accounts to determine if the payer paid the expected reimbursement amount. The managed care auditor, analyst, and collector are responsible for the identification of incorrectly paid accounts and the collection of the amount owed by the payer.
• MC Payment Review Process applies the concepts and tools discussed in previous courses to help calculate expected reimbursement. It is suggested that you complete “Introduction to Standard Managed Care Reimbursement Methods” prior to taking this course. This course provides you the opportunity to calculate reimbursement examples and become comfortable with the process of auditing. The most significant value of an efficient audit process is the end product, which is the use of audits to identify and track payer trends for future process improvement.
• Our Denials vs. Payment Variance courses addresses the issue that both denials and payment variances are consequences of break-downs in the revenue cycle and contribute to a breakdown or reduction in the hospital’s net income.
• Medicare Secondary Payer (MSP) will familiarize the student with MSP provisions and coordination of benefits payment methods.
• Silent Preferred Provider Organizations (PPOs) will help your facility to better identify PPO Network “Silent PPO” risk. Receiving the correct reimbursement from an insurance provider can be a difficult process; it becomes increasingly difficult when dealing with PPO networks that have a long list of network affiliates. Network contracts leave facilities vulnerable to non-contracted insurance carriers incorrectly assessing discounted contract rates.