Medicare and Medicaid Fundamentals

Unlike other businesses, healthcare provider organizations usually don’t receive payment directly from their customers (patients). Instead, they have to deal with the government and insurance companies in order to be paid. Reimbursement from these “third-party payers” is the source of most of their revenue.

Third-party payment is an absolutely key factor in your customers’ decision-making and priority-setting. If the reimbursement level drops for a particular procedure, use of that procedure often declines quickly. If reimbursement is tied to a particular goal – for instance, when Medicare began tying payment levels to certain patient outcomes – providers tend to move very fast to achieve that goal.

An understanding of third-party payers and their basic reimbursement rules and mechanisms is critical to your success in healthcare sales. It will help you speak your customers’ language and better understand their challenges.

This course will explain how your customers are reimbursed for the care they provide to their patients. It will focus primarily on the two biggest payers, Medicare and Medicaid, but will touch on private insurance plans as well.

Topics include:

• Reimbursement sources, including Medicare, Medicaid, and private insurance plans
• The importance of Medicare
• Coding systems
• Medicare payment systems for specific provider categories, including physicians, hospitals, labs, and post-acute providers