Module C: Medicare Reimbursement

CE Credits: 1.75


Regulations laid out by the Centers for Medicare & Medicaid Services (CMS), established primarily for Medicare, have set the tone for all of America’s health insurance plans. This module lays out the basics of how this system works, starting by describing the major federal plans, and then detailing what kinds of services Medicare covers. Next, the module draws a distinction between its two payment systems: the inpatient prospective payment system (IPPS) and the outpatient prospective payment system (OPPS).

Learning objectives: After completing this module case managers will be able to:
» Describe federal healthcare insurance coverage
» Examine the Medicare program and services
» Discuss reimbursement through the inpatient prospective payment system (IPPS)
» Review reimbursement through the outpatient prospective payment system (OPPS)


Advance your professional practice: Understanding the Medicare system is a vital part of being a CM. After all, the population eligible for Medicare will soon grow from one in every eight Americans to more than one in every five. Understanding the effect the federal government has on healthcare quality and reimbursement—especially in cases involving Medicare—is vital to a case management program’s success.

Improve organizational performance: A hospital’s ongoing sustainability depends on its ability to manage reimbursements. When the whole team has a grasp on Medicare’s system, we will be well equipped to work with the program and many other insurance plans that take their cues from it.