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 well as its impact on pay for performance incentives 2 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.
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 healthcare 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. 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 a healthcare organization. What would happen if services were provided to patients but no payments were received for these services?
B. Illustrate the flow of the patient through the cycle from the initial point of contact through the care and ending at the point where the payment is collected. Also identify the departments in order of importance to the revenue cycle. 3
II. Departmental Impact on Reimbursement
A. Many different departments utilize reimbursement data in a healthcare organization. It is crucial the healthcare organization monitors this data.What impact could the healthcare organization face if this data were not monitored? Describe why collecting data is required for pay-forperformance incentives.
B. Describe the activities within each department for how they may impact reimbursement. What specific data would you review in the reimbursement area to know whether changes were necessary?
C. Identify the responsible department for ensuring compliance with billing and coding policies. How does this affect the department’s impact on reimbursement in a healthcare organization?
III. Billing and Reimbursement
A. 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. How do third-party policies impact the payer mix for maximum reimbursement?
B. 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.
C. Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
D. 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. Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete evidence or research.
B. Discuss the resources needed to ensure billing and coding compliance with regulations.
C. Evaluate strategies to ensure stakeholders involved in the reimbursement process adhere to ethical standards. Milestones Milestone One: Draft of Reimbursement and the Revenue Cycle In Module Three, you will submit a draft of Sections I and II of the final project (Reimbursement and the Revenue Cycle, and Departmental Impact on Reimbursement). This milestone will be graded with the Milestone One Rubric.
Milestone Two: 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 Two 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. Guidelines for Submission:
This white paper should include a table of contents and sections that can be easily separated for each department area.
Expert Solution Preview
Reimbursement and the Revenue Cycle:
A. Reimbursement refers to the payment received by a healthcare organization for the services provided to patients. Without receiving payments for these services, the healthcare organization would face financial difficulties and may struggle to cover operational costs and investments. It could lead to a decrease in the quality of patient care and the ability to provide necessary resources and equipment.
B. The flow of the patient through the revenue cycle starts with the initial point of contact, such as scheduling an appointment or arriving at the emergency department. Then, it progresses through various departments, including registration, diagnosis and treatment, coding and billing, and ending at the point where the payment is collected. The departments that play a crucial role in the revenue cycle, in order of importance, include registration, coding and billing, and financial services. Registration ensures accurate patient identification and insurance verification, coding and billing ensures proper documentation and reimbursement claims submission, and financial services handles payment collection and reconciliation.
Departmental Impact on Reimbursement:
A. Monitoring reimbursement data is essential for a healthcare organization to understand its financial performance and identify areas for improvement. If the data is not monitored, the organization may face financial losses, decreased revenue, and difficulties in maintaining financial stability. Collecting data is required for pay-for-performance incentives because it allows the organization to measure and track the quality and efficiency of care provided. It ensures that reimbursement is aligned with the organization’s performance.
B. Each department within a healthcare organization has its own activities that impact reimbursement. For example, the registration department ensures accurate patient demographic and insurance information, the clinical departments provide documented services and procedures for coding and billing, and the financial services department manages the claims submission and reimbursement process. In the reimbursement area, specific data to review includes claim denial rates, average reimbursement per procedure, and revenue cycle timeframes. By analyzing this data, the organization can identify trends, gaps, and areas for improvement in the reimbursement process.
C. The responsible department for ensuring compliance with billing and coding policies is the coding and billing department. Compliance with billing and coding policies is crucial because any errors or non-compliance can lead to claim denials, potential audits, fines, and reputational damage for the healthcare organization. This department’s compliance directly impacts reimbursement as accurate and compliant claims are more likely to be reimbursed fully and in a timely manner.
Billing and Reimbursement:
A. When developing billing guidelines for patient financial services (PFS) personnel and administration, third-party policies are integral. Third-party policies outline the reimbursement rules and procedures for different payer types. By aligning with these policies, the PFS personnel and administration can maximize reimbursement by ensuring proper documentation, accurate coding, and timely claims submission. Third-party policies impact the payor mix for maximum reimbursement by determining the rates and conditions for reimbursement from each payor source.
B. Key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers include:
1. Claims accuracy and completeness: Ensuring claims are error-free, properly coded, and contain all necessary documentation to prevent claim denials and delays.
2. Timely claims submission: Submitting claims within the designated timeframe to avoid potential penalties and reduced reimbursement rates.
3. Contract management: Regularly reviewing managed care contracts to understand payment terms, specific reimbursement rates, and any changes that may impact billing and reimbursement.
4. Denial management: Monitoring and analyzing claim denials to identify trends and implement corrective measures to minimize future denials.
5. Compliance with regulatory requirements: Adhering to billing and coding regulations to avoid penalties and investigate any potential violations.
C. To structure the follow-up staff effectively, it is important to assign roles and responsibilities based on their expertise and experience. The structure can include different levels of staff, such as entry-level billers and coders, experienced auditors, and supervisors or managers. Training and ongoing education should be provided to ensure staff members stay updated with changes in reimbursement policies and regulations. Regular communication and collaboration between departments involved in the reimbursement process are also essential to ensure the effectiveness of the structure.
D. a plan for periodic review of procedures to ensure compliance can be enacted by following these steps:
1. Establish a Compliance Committee: Assign a team responsible for overseeing compliance with billing and coding procedures, including representatives from coding and billing, finance, legal, and clinical departments.
2. Develop Compliance Policies and Procedures: Create comprehensive policies and procedures that outline the organization’s commitment to compliance, specific coding and billing guidelines, and steps to follow in case of potential violations.
3. Conduct Regular Audits and Monitoring: Regularly review documentation, claims, and coding practices to identify any deviations or red flags. This can be done through internal audits or by engaging external auditors.
4. Implement Corrective Measures: Address any identified deficiencies through appropriate education and training programs for staff involved in the reimbursement process. Additionally, develop corrective action plans to rectify any billing or coding errors and prevent recurrence.
5. Maintain Documentation and Record Keeping: Document all compliance-related activities, including audits, training sessions, and corrective measures. This documentation helps demonstrate the organization’s commitment to compliance and acts as evidence in case of audits or investigations.
Marketing and Reimbursement:
A. New managed care contracts impact reimbursement for the healthcare organization by potentially altering the negotiated reimbursement rates and payment terms. These contracts can either increase or decrease reimbursement rates based on the negotiated terms. It is essential to evaluate the financial implications of these contracts and ensure that they support the organization’s financial sustainability and goals. Concrete evidence or research should be used to support this evaluation.
B. To ensure billing and coding compliance with regulations, adequate resources are needed. These resources include trained and certified coding and billing professionals who are knowledgeable about the latest coding guidelines and regulations. Additionally, technology systems and software should be implemented to support accurate documentation, coding, and claims submission.
C. Strategies to ensure stakeholders involved in the reimbursement process adhere to ethical standards include:
1. Implementing an Ethical Code of Conduct: Develop and communicate a code of conduct that includes ethical practices for all stakeholders involved in the reimbursement process. This code should emphasize honesty, accuracy, confidentiality, and compliance with all applicable laws and regulations.
2. Training and Education: Provide training sessions and educational programs to inform stakeholders about ethical considerations in the reimbursement process. This can include topics such as potential conflicts of interest, patient privacy, and billing and coding compliance.
3. Ongoing Monitoring and Auditing: Regularly monitor and audit the reimbursement process to identify any potential ethical violations. This can be done through internal audits or by engaging external auditors to ensure transparency and maintain ethical standards.
Note: The provided answers are fictional and may vary based on the specific requirements of the assignment.
