Training Course on Healthcare Reimbursement and Payer Relations

Module 1: Foundations of Healthcare Reimbursement
Introduction to Healthcare Financing
Historical evolution of reimbursement systems globally.
Role of payers in healthcare delivery and system sustainability.
Types of Payers
Public (government insurance schemes like Medicare, Medicaid, NHIF).
Private health insurance companies.
Hybrid systems (public-private partnerships).
Reimbursement Models
Fee-for-service: opportunities and inefficiencies.
Value-based reimbursement: linking payment to outcomes.
Managed care models and integrated delivery systems.
Core Concepts
Copayments, deductibles, co-insurance, and out-of-pocket limits.
Diagnosis-Related Groups (DRGs) and bundled payments.
Capitation and global budgets.
Activity: Participants map their country’s payer landscape and discuss strengths and gaps.

Module 2: Reimbursement Models and Payment Systems
Traditional Models
Fee-for-service: incentives, drawbacks, and overutilization risks.
Per diem and case-based payments: balancing costs and efficiency.
Value-Based Models
Pay-for-performance (P4P) systems tied to quality and safety indicators.
Shared savings programs and accountable care organizations (ACOs).
Risk-sharing and outcome-based contracts.
Prospective vs. Retrospective Payments
Case-mix adjusted prospective payments.
Cost-reimbursement approaches and their challenges.
Global Perspectives
Comparative analysis of reimbursement in the U.S., UK (NHS), and LMICs.
Trends in universal health coverage and their implications for reimbursement.
Case Study: Transition from fee-for-service to bundled payments in orthopedic surgery.

Module 3: Claims Management and Revenue Cycle Optimization
Revenue Cycle Overview
Pre-authorization requirements and insurance verification.
Patient registration, eligibility checks, and financial counseling.
Medical Coding and Documentation
ICD-10, CPT, and HCPCS coding systems.
Importance of accurate clinical documentation for reimbursement.
Claims Submission and Adjudication
Electronic vs. paper claim submission processes.
Payer adjudication rules and remittance advice.
Denials and Appeals
Common denial reasons (coding errors, missing documentation, late submissions).
Appeal processes and strategies for recovery.
Optimizing Revenue Cycle Management (RCM)
Key performance indicators (KPIs): days in accounts receivable, denial rates, collection rates.
Use of RCM software, predictive analytics, and automation tools.
Exercise: Hands-on review of sample claims to identify errors and propose corrective measures.

Module 4: Payer Relations and Negotiation Strategies
Building Collaborative Relationships
Payer-provider trust and transparency.
Role of data sharing in payer relations.
Contract Negotiation
Understanding payer contracts: terms, reimbursement rates, utilization reviews.
Negotiating clauses for quality-based incentives and performance bonuses.
Handling disputes over reimbursement rates or service coverage.
Risk-Based Contracts
Capitation and shared-risk models.
Aligning clinical and financial outcomes.
Conflict Management
Identifying and resolving disputes with payers.
Mediation techniques and escalation strategies.
Simulation: Mock contract negotiation between a hospital administrator and an insurance payer.

Module 5: Compliance, Ethics, and Future Trends in Reimbursement
Regulatory Environment
Anti-kickback statutes, Stark Law, False Claims Act.
Country-specific regulations (e.g., HIPAA in the U.S., GDPR in Europe).
Fraud, Waste, and Abuse Prevention
Detecting fraudulent billing and upcoding.
Establishing compliance programs and internal audits.
Ethical Issues in Reimbursement
Balancing cost control with patient care.
Addressing inequities in access to reimbursable care.
Emerging Trends
Telemedicine reimbursement policies and challenges.
Digital health tools and remote patient monitoring payment models.
Artificial intelligence in claims adjudication and fraud detection.
Value-based contracts for precision medicine and gene therapies.
Capstone Project
Participants design a reimbursement and payer-relations strategy for a healthcare facility introducing a new service (e.g., telehealth, specialized surgery).