Module E: Commercial Reimbursement

CE Credits: 1.5


This module explores how the processes surrounding reimbursement can change when dealing with common commercial plans. It begins by looking at the different types of plans, and then explores one big factor in commercial health plans: high deductibles, which can have a significant effect on revenue flow. The module then details different strategies for regarding denials from commercial plans, and how CMs can help hospitals avoid such denials—such as the proper documentation of contracts and data.

Learning objectives: After completing this module case managers will be able to:
» Review the types of and differences in commercial plans
» Describe the effect of high deductible plans on revenue flow
» Discuss the effect of commercial health plan contracts on claims and reimbursement
» Describe strategies to improve commercial claims reimbursement
» Review types of health plans and the MCO CM role in improving outcomes


Advance your professional practice: As frontline players with insurance claims, CMs need to learn commercial payer terminology, as well as strategies to help ensure compliance with guidelines. When used together, such tactics can help ensure proper reimbursement.

Improve organizational performance: Reimbursement is a huge challenge for hospitals, and commercial plans offer their own obstacle courses of requirements that hospitals must navigate in order to get reimbursed for services. When the whole team appreciates the level of data and documentation that can help achieve better reimbursement, we can work together for a more streamlined, productive process.