Week 1 discussion
Interrelationship Between
the Revenue Cycle and Reimbursement
In your post, analyze the
interrelationship between the revenue cycle and reimbursement and assess its
contributors. Think about questions such as how revenue is generated throughout
the healthcare organization, which departments impact revenue as well as
reimbursement, and what would happen if no payments were received. How would
you describe the interrelationship between the revenue cycle and reimbursement?
What seems to be working? What seems to need improvements? Please refer to the
readings as support for your answer.
Week 2 discussion
Daily Activities and
Reimbursement
In your post, analyze and
describe how the activities within each department at a hospital impact
reimbursement. Choose three procedures and explain each step of a patient visit
for each of these three procedures.
Week 3 discussion
Claims Processing and
Reimbursement
In your post, compare and
contrast various payers and suppliers and the claims filing process. How
important are ethics with claims processing? Explain how ethics can impact
payer mix and reimbursement.
Week 4 discussion
Prospective Payment
Systems and Reimbursement
In your post, compare and
contrast prospective payment systems with non-prospective payment systems.
Explain the classification systems used with prospective payments. How do the
prospective payment systems impact operations?
Week 5 discussion
Pay for Performance and
Attention to Details
In your post, evaluate
how reimbursement data can be used for pay for performance incentives. How
important is it to have a dedicated position to focus on the details of the
various plans? What are some strengths and pitfalls around paying attention to
details in healthcare reimbursement?
Week 6 discussion
Additional Regulations
In your post, evaluate
meaningful use regulations for recovery audit contractors (RACs) and electronic
health records (EHRs), as well as the impact on either case management or
performance incentives. What is the purpose of these regulations? How effective
are they in meeting the purpose? Support your answer with course resources.
Week 7 discussion
Fraud and Abuse
In your post, critique
legal and ethical practices to prevent fraud and abuse. Have the practices been
effective in reducing or preventing fraud and abuse? How does fraud and abuse
impact the costs of healthcare?
Milestone One
HCM 345 Milestone One
Guidelines and Rubric
Overview: 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.
Milestone One provides
you an opportunity to engage with real-world data and tools that you would
encounter in an actual professional environment.
Specifically, you will
begin thinking about the purpose of reimbursement and how it impacts other
healthcare departments. You will also practice analyzing the
revenue cycle.
Prompt: Submit a draft of
your Section I of the final project. Specifically, the following critical
elements must be addressed:
I. Reimbursement and the
Revenue Cycle
A. Describe what
reimbursement means to this specific healthcare organization. What would happen
if services were provided to patients but no
payments were received
for these services? What specific data would you review in the reimbursement
area to know whether changes were
necessary?
B. Illustrate the revenue
cycle using a flowchart tool. Take the patient through the cycle from the
initial point of contact through the care and
ending at the point where
the payment is collected.
C. Prioritize the
departments at this specific healthcare organization in order of their
importance to the revenue cycle. Support your ordering of the
departments with
evidence.
Guidelines for
Submission: Your draft must be submitted as a three- to four-page Microsoft
Word document with double spacing, 12-point Times New Roman
font, one-inch margins,
and at least three sources, which should be cited in APA format.
Instructor Feedback: This
activity uses an integrated rubric in Blackboard. Students can view instructor
feedback in the Grade Center. For more information,
review these
instructions.
Milestone Two
HCM 345 Milestone Two
Guidelines and Rubric
Overview: 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.
Milestone Two provides
you an opportunity to engage with real-world data that you would encounter in
an actual professional environment. Specifically, you will
take a closer look at how
reimbursement impacts other healthcare departments, and you will dive deep into
utilizing data, tracking records, and ensuring
compliance within
individual departments.
Prompt: Submit a draft of
Section II of the final project. Specifically, the following critical elements
must be addressed:
II. Departmental Impact
on Reimbursement
A. Describe the impact of
the departments at this healthcare organization that utilize reimbursement
data. What type of audit would be necessary
to determine whether the
reimbursement impact is reached fully by these departments? How could the
impact of these departments on pay-forperformance
incentives be measured?
B. Assess the activities
within each department at this healthcare organization for how they may impact
reimbursement.
C. Identify the
responsible department for ensuring compliance with billing and coding
policies. How does this affect the department’s impact on
reimbursement at this
healthcare organization?
Guidelines for
Submission: Your paper must be submitted as a three- to four-page Microsoft Word
document with double spacing, 12-point Times New Roman
font, one-inch margins,
and at least three sources, which should be cited in APA format.
Instructor Feedback: This
activity uses an integrated rubric in Blackboard. Students can view instructor
feedback in the Grade Center. For more information,
review these
instructions.
Milestone Three
HCM 345 Milestone Three
Guidelines and Rubric
Overview: 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.
Milestone Three provides
you an opportunity to engage with real-world data and tools that you would
encounter in an actual professional environment.
Specifically, you will
begin thinking about reimbursement in terms of billing and marketing.
Reimbursement is a complex process with several stakeholders; this
milestone allows you to
begin thinking about the key players, including third-party billing, data
collection, staff management, and ensuring compliance.
Marketing and
communication also plays a vital role in reimbursement; this milestone offers a
chance to begin analyzing effective strategies and their impact.
Prompt: Submit your draft
of Sections III and IV of the final project. Specifically, the following
critical elements must be addressed:
III. Billing and
Reimbursement
A. Analyze the collection
of data by patient access personnel and its importance to the billing and
collection process. Be sure to address the
importance of exceptional
customer service.
B. Analyze how
third-party policies would be used when developing billing guidelines for
patient financial services (PFS) personnel and
administration when
determining the payer mix for maximum reimbursement.
C. Organize the key areas
of review in order of importance for timeliness and maximization of
reimbursement from third-party payers. Explain your
rationale on the order.
D. Describe a way to
structure your follow-up staff in terms of effectiveness. How can you ensure
that this structure will be effective?
E. Develop a plan for
periodic review of procedures to ensure compliance. Include explicit steps for
this plan and the feasibility of enacting this plan
within this organization.
IV. Marketing and
Reimbursement
A. Analyze the strategies
used to negotiate new managed care contracts. Support your analysis with
research.
B. Communicate the
important role that each individual within this healthcare organization plays
with regard to managed care contracts. Be sure to
include the different
individuals within the healthcare organization.
C. Explain how new
managed care contracts impact reimbursement for the healthcare organization.
Support your explanation with concrete
evidence or research.
D. Discuss the resources
needed to ensure billing and coding compliance with regulations and ethical
standards. What would happen if these
resources were not
obtained? Describe the consequences of noncompliance with regulations and
ethical standards.
Guidelines for
Submission: Your draft must be submitted as a three- to five-page Microsoft
Word document with double spacing, 12-point Times New Roman
font, one-inch margins,
and at least three sources, which should be cited in APA format.
Instructor Feedback: This
activity uses an integrated rubric in Blackboard. Students can view instructor
feedback in the Grade Center. For more information,
review these
instructions.
Final Project
HCM 345 Final Project
Guidelines and Rubric
Overview
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 three 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 One, Three, and Five.
In this assignment, you
will demonstrate your mastery of the following course outcomes:
? Analyze the impacts of
various healthcare departments and their interrelationships on the revenue
cycle
? Compare third-party
payer policies through analysis of reimbursement guidelines for achieving
timely and maximum reimbursements
? Analyze organizational
strategies for negotiating healthcare contracts with managed care organizations
? Critique legal and
ethical standards and policies in healthcare coding and billing for ensuring
compliance with rules and regulations
? Evaluate the use of
reimbursement data for its purpose in case and utilization management and
healthcare quality improvement as well as its impact on
pay for performance
incentives
Prompt
You 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.
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. Reimbursement and the
Revenue Cycle
A. Describe what
reimbursement means to this specific healthcare organization. What would happen
if services were provided to patients but no
payments were received
for these services? What specific data would you review in the reimbursement
area to know whether changes were
necessary?
B. Illustrate the revenue
cycle using a flowchart tool. Take the patient through the cycle from the
initial point of contact through the care and
ending at the point where
the payment is collected.
C. Prioritize the
departments at this specific healthcare organization in order of their
importance to the revenue cycle. Support your ordering of the
departments with
evidence.
II. Departmental Impact
on Reimbursement
A. Describe the impact of
the departments at this healthcare organization that utilize reimbursement
data. What type of audit would be necessary
to determine whether the
reimbursement impact is reached fully by these departments? How could the
impact of these departments on pay-forperformance
incentives be measured?
B. Assess the activities
within each department at this healthcare organization for how they may impact
reimbursement.
C. Identify the
responsible department for ensuring compliance with billing and coding
policies. How does this affect the department’s impact on
reimbursement at this
healthcare organization?
III. Billing and
Reimbursement
A. Analyze the collection
of data by patient access personnel and its importance to the billing and
collection process. Be sure to address the
importance of exceptional
customer service.
B. Analyze how
third-party policies would be used when developing billing guidelines for
patient financial services (PFS) personnel and
administration when
determining the payer mix for maximum reimbursement.
C. Organize the key areas
of review in order of importance for timeliness and maximization of
reimbursement from third-party payers. Explain your
rationale on the order.
D. Describe a way to
structure your follow-up staff in terms of effectiveness. How can you ensure
that this structure will be effective?
E. Develop a plan for
periodic review of procedures to ensure compliance. Include explicit steps for
this plan and the feasibility of enacting this plan
within this organization.
IV. Marketing and
Reimbursement
A. Analyze the strategies
used to negotiate new managed care contracts. Support your analysis with
research.
B. Communicate the
important role that each individual within this healthcare organization plays
with regard to managed care contracts. Be sure to
include the different
individuals within the healthcare organization.
C. Explain how new
managed care contracts impact reimbursement for the healthcare organization.
Support your explanation with concrete
evidence or research.
D. Discuss the resources
needed to ensure billing and coding compliance with regulations and ethical
standards. What would happen if these
resources were not
obtained? Describe the consequences of noncompliance with regulations and
ethical standards.
Milestones
Milestone One: Draft of
Reimbursement and the Revenue Cycle
In Module One, you will
submit a draft of Section I of the final project (Reimbursement and the Revenue
Cycle). This milestone will be graded with the
Milestone One Rubric.
Milestone Two: Draft of
Departmental Impact on Reimbursement
In Module Three, you will
submit a draft of Section II of the final project (Departmental Impact on
Reimbursement). This milestone will be graded with the
Milestone Two Rubric.
Milestone Three: Draft of
Billing, Marketing, and Reimbursement
In Module Five, you will
submit a draft of Sections III and IV of the final project (Billing and
Reimbursement, and Marketing and Reimbursement). This milestone
will be graded with the
Milestone Three Rubric.
Final Project Submission:
White Paper
In Module Seven, you will
submit your entire white paper. It should be a complete, polished artifact
containing all of the critical elements of the final product. It
should reflect the
incorporation of feedback gained throughout the course. This submission will be
graded using the Final Project Rubric.
2-2 Journal: Compliance,
Coding, and Reimbursement
Research three billing
and coding regulations that impact healthcare organizations. Reflect on how
these regulations affect reimbursement in a healthcare organization. Comment on
what seems to work well and what could be improved. If possible, bring in a
real-world example either from your life or from something you have read about.
4-2 Journal: Payment
Systems
Compare and contrast the
various billing and coding regulations researched in Module Two to determine
which ones apply to prospective payment systems. Reflect on how these
regulations affect reimbursement in a healthcare organization. Assess the
impact of regulations on reimbursement in a healthcare organization and explain
what you think is working and what could be a challenge. If possible, bring in
a real-world example either from your life or from something you have read
about.
8-1 Journal: Course
Reflection
Select three topics that
were presented in this course and assess how these are applied in a healthcare
facility. In your examination, consider how these concepts will help you in
other courses that are required for your healthcare degree.
