Health Care Reimbursement Training Plan

NUR-621 Health Care Reimbursement Training Plan





Enhancing Effectiveness


Health Care Reimbursement Training
Training Summary and Focus In the nursing profession, attaining competency is an essential part of the health care system. Professional skills are required in the health care system to optimize the quality of health care services. Enhancing the effectiveness of the workers implies that this training would focus on addressing how nurses can enhance their effectiveness in care through financial reimbursements obtained from Medicaid and Medicare, and private insurance programs (Oliver et al., 2020). These skills play an essential role in the health care system in the US as it defines the primary objective of the US health care system (Penner, 2017).
Specific Learning Target(s)/Objectives Objective 1: Explaining Public Insurance to nurses

The need to improve the health care delivery method while reducing the cost of health care has compelled the US government to develop a financial system that takes care of the health care costs. The programs developed by the US government include Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) (Altman & Frist, 2015). These programs are essential in the performance of major health care activities in the US. Besides, they have an impact on the taxpayers because of the budget allocation made by the government of these programs each financial year. The three major health care programs insure citizens at different levels. For instance, Medicare is the insurance cover for older people above 65 years in the US, while Medicaid and young adults generate while CHIP is for children across the US.

Objective 2: Risks and Uncertainties when working with healthcare reimbursements.

The effectiveness of the health care system in the US comes from public and private reimbursements. However, these types of health reimbursement come with varying levels of uncertainties. The process of healthcare reimbursement comes in two different forms. The first category is private players that entails an employer-based cover and personal purchased insurance. The private providers require a deductible that can reimburse funds directly to the provider. The second category is the public players representing Medicare Medicaid, representing 25 percent of all the US health care systems. Each insurer, either public or private, has regulations that affect their cover.

Training Outline The training will focus on how the public insurance programs are designed to facilitate value-based care on increasing quality and reducing the cost of health care (Garrison & Towse, 2017).

Training objectives for Medicaid Program

This program supports the ACA act that aids in expanding health coverage to all US citizens to receive better health care. The need to meet the expansion of health care efforts to many people and in areas that have not experienced this program is a mission of the government to reduce cost and increase the accessibility of health care.

Training objective on Medicare program

The program offers plans for outpatient services and inpatient services. The program focuses on value-based care and transformation to other alternative payments methods. The program focuses on under bundled payment methods to reduce cost.

Resources, Materials, Equipment, and Technology This training will use various instructional materials such as presentation, content, and delivery system.

The instructional materials proposed for use in this training will be written and demonstrated using visual aids to heighten the trainees’ understanding.

The technology applied in training nurses will involve Electronic Medical Records (EMRs), medical supplies, and computers.

References Altman, D., & Frist, W. H. (2015). Medicare and Medicaid at 50 years: perspectives of beneficiaries, health care professionals and institutions, and policymakers. Jama314(4), 384-395. doi:10.1001/jama.2015.7811

Garrison, L. P., & Towse, A. (2017). Value-based pricing and reimbursement in personalized healthcare: introduction to the basic health economics. Journal of Personalized Medicine7(3), 10.

Oliver, T. L., Qi, B. B., Shenkman, R., Diewald, L., & Smeltzer, S. C. (2020). Weight sensitivity training among undergraduate nursing students. Journal of Nursing Education59(8), 453-456.

Penner, S. J. (2017). Economics and financial management for nurses and nurse leaders. Springer Publishing Company.

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NUR-621 Health Care Reimbursement Training Plan







Health Care Reimbursement Training
Training Summary and Focus The training process involves how Medicare, Medicaid, and private insurance reimburse healthcare organizations for the services delivered. The central focus is the contribution of the health insurance company’s and policies on the enhancement of the delivery of quality healthcare services at affordable rates. The entire process of training is supposed to equip the new employees with skills on how to unravel healthcare reimbursement issues, including improperly coded claims, the transition from the fee-for-service to the value-based payment methods, as well as the layer of complexity to the already highly detailed reimbursement systems.



Specific Learning Target(s)/Objectives In the process of training, learners are expected to acquire specific skills and knowledge on Medicare, Medicaid, and private insurance reimburse in the healthcare system. Some of the objectives in the training process include:

·         To describe current reimbursement methods and provide the analysis of their impacts on the drug and the device used and innovation

·         To make employees understand the processes of Medicare, Medicaid, and private insurance reimbursement system to enhance efficiency and quality of treatment and medication to all irrespective of income.

·         To understand the processes including the assessments of the impacts of the reimbursement on the healthcare innovations based on the economic theories, consultations with experts, and literature reviews.

·         Finally, the aim of the training process is to identify the essential or key characteristics of the reimbursement and how they impact the healthcare system and the quality of treatments and medication.



With the above objectives, the whole process of training with revolve around the health insurance policies. First, there will be an explanation of the roles of Medicare, Medicaid, and Private insurance policies. Secondly, there will be the explanation and elaboration of the compensation mechanisms.

In the process of training, the learners should the exposed to the variety of factors that impact that Medicaid reimbursement methods as well as the criteria that often remain fairly universal. Before embarking on the discussion on the reimbursement processes; it is imperative that learners or the employees are given a good understanding of various Medicaid models including:

·         The managed care model

·         The free-for-service model

Finally, there will be an elaboration of the Medicaid system; how the money is generated and how it benefits each person enrolled to it. In addition, there will be an explanation of the complexities involved in the reimbursement mechanisms.

Similarly, for the Medicaid and private insurance, there will be an elaboration of the reimbursement mechanisms, as well as the complexities involved during the training processes (Harrington, 2016).

In the economic perspectives, the training process will incorporate the understanding of economic index of Medicaid, Medicare, and private plans and how they work in favor of both the beneficiaries and the healthcare institutions. The economic index refers to the measure of practice cost inflation developed in the year 1975 to enhance measurement of annual changes in the operating costs as well as the learning levels of doctors depending on the inflation and the cost of service provisions (Green, 2014)

Finally, trainees will be made aware of who is happy with the systems of Medicaid, Medicare and private insurance and who is not. In most cases, states are pro these models for different reasons, first, they pay the capitated fee for these plans which can bring down the total costs. Also, the states prefer these plans because they transfer the financial risks away from the state budgets and the general responsibilities to control the healthcare providers (Casto & American Health Information Management Association, 2018).  

Training Outline  


I.            Introducing the Medicaid, Medicare, and Private insurance plan

i.            Stating the importance of these insurance plans

ii.            Elaborating on the implementation processes


I.                     Elaborating on who is eligible or who can qualify for the Medicaid, Medicare, and private insurance plans

II.                 Highlighting conditions that can make an individual qualify for the plans

Form of Medicaid, Medicare and Private Insurance Plans

I.                    Elaboration on different forms of Medicaid, Medicare and Private Insurance Plans

II.                  Explanation of cost-effectiveness and the economies of scale under each category

Reimbursement Procedures

I.                    An elaboration of how the money is generated and how it benefits each person enrolled to it.

II.                 Explanation of the complexities involved in the reimbursement mechanisms, and the costs associated with each plan.

III.                Elaboration of the benefits that comes with each healthcare insurance plan and the procedure of enrollments

Stakeholders involved

I.                    Finally, the training program will involves understanding the people and the organizations that are involved in the reimbursement of different healthcare insurance plans and how their activities are controlled by the state and federal governments for the benefits of the population.


Resources, Materials, Equipment, and Technology Some of the resources that will be used include:

·         Medicaid insurance policy document

·         Medicare insurance policy document

·         Private insurance policy documents

·         Different samples of reimbursement documents from various hospitals and other health facilities

·         Constitution

Equipment to be employed include:

·         Computers with internet access to enhance retrieval of information











References  Casto, A. B., & American Health Information Management Association,. (2018). Principles of healthcare reimbursement.

Green, M. A. (2014). Understanding health insurance: A guide to billing and reimbursement.

Harrington, M. K. (2016). Health care finance and the mechanics of insurance and reimbursement.



Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be

at least 250 words.

Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.

One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.

I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.

In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.

Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).

Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).

Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.

I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.

As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.

It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.


Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.