The final project for this course is the creation of a white paper.
Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization. Reimbursement drives the financial operations of healthcare organizations; each department affects the reimbursement process regarding timelines and the amount of money put into and taken out of the system. However, if departments do not follow the guidelines put into place or do not capture the necessary information, it can be detrimental to the reimbursement system.
An important role for patient financial services (PFS) personnel is to monitor the reimbursement process, analyze the reimbursement process, and suggest changes to help maximize the reimbursement. One way to make this process more efficient is by ensuring that the various departments and personnel are exposed to the necessary knowledge.
For your final project, you will assume the role of a supervisor within a PFS department and develop a white paper in which the necessary healthcare reimbursement knowledge is outlined.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five.
In this assignment, you will demonstrate your mastery of the following course outcomes:
- HCM-345-01: Analyze the impacts of various healthcare departments and their interrelationships on the revenue cycle
- HCM-345-02: Compare third-party payer policies through analysis of reimbursement guidelines for achieving timely and maximum reimbursements
- HCM-345-03: Analyze organizational strategies for negotiating healthcare contracts with managed care organizations
- HCM-345-04: Critique legal and ethical standards and policies in healthcare coding and billing for ensuring compliance with rules and regulations
- HCM-345-05: Evaluate the use of reimbursement data for its purpose in case and utilization management and healthcare quality improvement as wellas its impact on pay for performance incentivesPromptYou are now a supervisor within the patient financial services (PFS) department of a healthcare system. It has been assigned to you to write a white paper to educate other department managers about reimbursement. This includes how each specific department impacts reimbursement for services, which in turn impacts the healthcare organization as a whole. The healthcare system may include hospitals, clinics, long-term care facilities, and more. For now, your boss has asked you to develop a draft of this paper for the hospital personnel only; in the future, there may be the potential to expand this for other facilities.
1
In order to complete the white paper, you will need to choose a hospital. You can choose one that you are familiar with or create an imaginary one. Hospitals vary in size, location, and focus. Becker’s Hospital Review has an excellent list of things to know about the hospital industry. Once you have determined the hospital, you will need to think about the way a patient visit works at the hospital you chose so you can review the processes and departments involved. There are several ways to accomplish this. Choose one of the following:
- If you have been a patient in a hospital or if you know someone who has, you can use that experience as the basis for your responses.
- Conduct research through articles or get information from professional organizations. Below is an example of how to begin framing your analysis.A patient comes in through the emergency department. In this case, the patient would be triaged and seen in the emergency department. Think about what happens in an emergency area. The patient could be asked to change into a hospital gown (think about the costs of the gown and other supplies provided). If the patient is displaying signs of vomiting, plastic bags will be provided and possibly antinausea medication. Lab work and possibly x-rays would be done. The patient could be sent to surgery, sent home, or admitted as an inpatient. If he or she is admitted as an inpatient, meals will be provided and more tests will be ordered by the physician—again, more costs and charges for the patient bill. Throughout the course, you will be gathering additional information through your readings and supplemental materials to help you write your white paper.When drafting this white paper, bear in mind that portions of your audience may have no healthcare reimbursement experience, while others may have been given only a brief overview of reimbursement. The goal of this guide is to provide your readers with a thorough understanding of the importance of their departments and thus their impact on reimbursement. Be respectful of individual positions and give equal consideration to patient care and the business aspects of healthcare. Consider written communication skills, visual aids, and the feasibility to translate this written guide into verbal training.Specifically, the following critical elements must be addressed:
I.
II.
Reimbursement and the Revenue Cycle
- Describe what reimbursement means to a healthcare organization. What would happen if services were provided to patients but no payments werereceived for these services?
- Illustrate the flow of the patient through the cycle from the initial point of contact through the care and ending at the point where thepayment is collected. Also identify the departments in order of importance to the revenue cycle.
Departmental Impact on Reimbursement
- Describe the impact of the departments in a healthcare organization that utilize reimbursement data. What type of audit would be necessary todetermine whether the reimbursement impact is reached fully by these departments? How could the impact of these departments on pay-for-performance incentives be measured?
- Assess the activities within each department at this healthcare organization for how they may impact reimbursement. What specific data would youreview in the reimbursement area to know whether changes were necessary?
- Identify the responsible department for ensuring compliance with billing and coding policies. How does this affect the department’s impact onreimbursement in a healthcare organization?
2
III. Billing and Reimbursement
- Analyze the collection of data by patient access personnel and its importance to the billing and collection process. Be sure to address theimportance of exceptional customer service.
- Analyze how third-party policies would be used when developing billing guidelines for patient financial services (PFS) personnel andadministration when determining the payer mix for maximum reimbursement.
- Organize the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain yourrationale on the order.
- Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
- Develop a plan for periodic review of procedures to ensure compliance. Include explicit steps for this plan and the feasibility of enacting this planwithin this organization.
IV. Marketing and Reimbursement
- Analyze the strategies used to negotiate new managed care contracts. Support your analysis with research.
- Communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts. Be sure toinclude the different individuals within the healthcare organization.
- Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concreteevidence or research.
- Discuss the resources needed to ensure billing and coding compliance with regulations and ethical standards. What would happen if theseresources were not obtained? Describe the consequences of noncompliance with regulations and ethical standards.
Expert Solution Preview
Introduction:
The white paper assignment for this course is focused on educating other department managers on healthcare reimbursement. As a supervisor within the patient financial services department, the task is to develop a comprehensive guide on reimbursement for hospital personnel. The paper must cover the impact of different departments on reimbursement, the billing and reimbursement process, and the marketing aspect of reimbursement. In this assignment, the focus will be on how to complete the white paper by choosing a hospital and understanding the patient visit flow.
1. To complete the white paper, the first step is to choose a hospital and understand the patient visit flow. This can be done by using personal experience, conducting research via articles, or getting information from professional organizations. Understanding the patient visit flow is crucial to reviewing the processes and departments involved. It is important to consider the audience of the white paper and provide a thorough understanding of the importance of each department and its impact on reimbursement.
II. Reimbursement and the Revenue Cycle
– Reimbursement means payment for services provided; without payments, the healthcare organization cannot function properly.
– The flow of the patient through the cycle starts from the initial point of contact, then care, and ends where payment is collected. In order of importance to the revenue cycle, the departments are patient access, coding/billing, case management, and finance.
III. Departmental Impact on Reimbursement
– Departments that utilize reimbursement data have an impact on reimbursement. An audit would be necessary to determine whether the impact of these departments is fully reached. The impact of these departments on pay-for-performance incentives can be measured by analyzing patient outcomes.
– The activities within each department can impact reimbursement. Specific data that would be reviewed in the reimbursement area includes charge capture, claim submission, and denial management.
– The responsible department for ensuring compliance with billing and coding policies is the coding/billing department. Compliance affects the department’s impact on reimbursement in a healthcare organization.
IV. Billing and Reimbursement
– Patient access personnel collect data that is important to the billing and collection process. Exceptional customer service during this stage is vital for maximum reimbursement.
– When developing billing guidelines, third-party policies should be considered. The payer mix for maximum reimbursement with the third-party payer should be determined by patient financial services (PFS) personnel and administration.
– The key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers are eligibility verification, preauthorization, charge capture, and denial management. Priority is given to the stage that generates the most revenue.
– The structure of the follow-up staff should be based on patient responsibility, and follow-up procedures should be based on the age of the account.
– A plan for periodic review of procedures to ensure compliance should include quarterly reviews of claim edits, educational reminders, and feedback from departments.
V. Marketing and Reimbursement
– Strategies used to negotiate new managed care contracts need to be analyzed. Research is required to understand the best practices for successful negotiations.
– The important role that each individual plays in managed care contracts needs to be communicated. This includes various individuals in the healthcare organization, such as physicians and case managers.
– New managed care contracts impact reimbursement for the healthcare organization. Understanding the impact on reimbursement can help the organization determine whether the contract should be signed or renegotiated.
– Resources are required to ensure billing and coding compliance with regulations and ethical standards. Failure to obtain these resources can lead to consequences such as fines, decreased revenue, and legal action.
