AMBA CMRS study plan
AMBA CMRS · Give each week a clear focus.
8 weeks · About 7 hours per week
Coding and Charge Capture & Compliance, Fraud and Abuse, and Payer Regulations
Differentiate between ICD-10-CM, CPT, and HCPCS Level II code sets and their specific uses in billing.
Apply correct modifier usage (e.g., -25, -59, -26, -TC) to resolve common coding edits and bundling issues.
Identify key fraud and abuse laws (False Claims Act, Anti-Kickback Statute, Stark Law) and their implications for billing practices.
Explain the components of the OIG Compliance Program for physician practices and how to implement a coding compliance audit.
Your checkpoint
Create a one-page cheat sheet summarizing code set purposes, modifier rules, and fraud/abuse law penalties, with at least 5 example scenarios.
Coding and Charge Capture & Claims Submission and Clearinghouse Processes
Calculate expected reimbursement for common procedures using fee schedules (Medicare Physician Fee Schedule, APC) and payer contracts.
Describe the claims submission workflow from charge entry through clearinghouse to payer, including electronic and paper claims.
Identify common claim edits (NCCI, MUE, LCD/NCD) and apply corrective actions to prevent rejections.
Complete a CMS-1500 claim form accurately using a provided patient encounter scenario.
Your checkpoint
Complete a mock CMS-1500 claim form for a multi-procedure office visit, including correct modifiers, diagnosis linkage, and expected reimbursement calculation.
Payer Adjudication and Reimbursement Methodologies & Denial Management and Appeals
Compare reimbursement methodologies: fee-for-service, capitation, DRG, APC, and value-based models, and their impact on revenue cycle.
Interpret remittance advices (ERAs) to identify paid, denied, and adjusted claims, and post payments accurately.
Analyze common denial reasons (CO-16, CO-97, CO-197, PR-1, etc.) and determine appropriate appeal strategies.
Draft a level-one appeal letter for a medical necessity denial using supporting documentation.
Your checkpoint
Create a denial management flowchart that maps denial categories to corrective actions, and write one appeal letter for a denied claim.
Accounts Receivable and Collections & Patient Financial Responsibility and Counseling
Calculate key AR metrics: days in AR, AR aging percentages, collection rates, and net collection ratio.
Apply patient financial responsibility concepts: deductibles, coinsurance, copayments, and out-of-pocket maximums.
Design a patient financial counseling script that explains estimates and payment options while maintaining compliance with price transparency rules.
Evaluate collection strategies (in-house vs. agency) and the impact of charity care and financial assistance policies.
Your checkpoint
Produce an AR aging report analysis for a simulated practice, including calculated metrics and a patient financial counseling script.
Patient Access and Registration & Revenue Cycle Management and Performance Improvement
Verify patient eligibility and benefits using real-time tools and interpret responses for coverage and financial responsibility.
Implement front-end processes: pre-registration, insurance verification, prior authorization, and point-of-service collections.
Identify key performance indicators (KPIs) across the revenue cycle and set benchmarks for improvement.
Conduct a root cause analysis of a front-end process failure that leads to denials or delayed reimbursement.
Your checkpoint
Develop a patient access quality checklist and a KPI dashboard template with at least 5 metrics and target benchmarks.
Healthcare Billing Technology and Data Integrity & Claims Submission and Clearinghouse Processes
Evaluate billing software features for claim scrubbing, eligibility verification, and denial management.
Explain data integrity principles: accurate data entry, audit trails, and HIPAA security safeguards.
Demonstrate how to generate and interpret standard revenue cycle reports (e.g., claim status, denial trends).
Identify interoperability standards (EDI 837/835, 270/271) and their role in claims processing.
Your checkpoint
Create a technology assessment matrix comparing three billing systems based on features, cost, and compliance capabilities.
Compliance, Fraud and Abuse, and Payer Regulations & Denial Management and Appeals
Apply payer-specific regulations (Medicare, Medicaid, commercial) to billing scenarios, including timely filing and appeal deadlines.
Conduct a mock internal audit of 10 claims to identify coding and billing errors, and propose corrective actions.
Develop a compliance plan for a small practice that includes training, monitoring, and reporting mechanisms.
Analyze appeal outcomes and use data to refine denial prevention strategies.
Your checkpoint
Complete a mock audit report with findings, corrective action plan, and a one-page compliance policy summary.
Revenue Cycle Management and Performance Improvement & Accounts Receivable and Collections
Synthesize revenue cycle concepts by performing a comprehensive case study analysis of a practice's revenue cycle.
Calculate and interpret the revenue cycle's impact on days in AR and cash flow.
Design a performance improvement project using PDSA or Lean methodology to address a revenue cycle bottleneck.
Review all domains and complete a practice exam, scoring at least 80%.
Your checkpoint
Submit a final revenue cycle improvement plan that includes a case study analysis, PDSA project outline, and practice exam score report.
Milestones
Week 2: Successfully submit a clean mock claim with no errors and correctly calculate expected reimbursement.
Week 4: Achieve at least 75% on a quiz covering domains 1-5 and produce an accurate AR metric calculation.
Week 6: Score at least 80% on a midterm practice exam covering all domains and complete a technology assessment.
Week 8: Score at least 80% on a full-length practice exam and submit a comprehensive revenue cycle improvement plan.