HCM 345 SNHU Healthcare Reimbursement and The Revenue Cycle For your final project, you will assume the role of a supervisor within a PFS department and de | Homework Answers
HCM 345 SNHU Healthcare Reimbursement and The Revenue Cycle 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. HCM 345 Final Project Guidelines and Rubric
The final project for this course is the creation of a white paper.
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.
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:
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
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. Beckers 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 physicianagain, 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 departments 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.
Deliverables
Milestone
One
Two
Three
Deliverable
Draft of Reimbursement and the Revenue
Cycle
Draft of Departmental Impact on
Reimbursement
Draft of Billing, Marketing, and
Reimbursement
Final Project Submission: White Paper
Module Due
Grading
One
Graded separately; Milestone One Rubric
Three
Graded separately; Milestone Two Rubric
Five
Graded separately; Milestone Three Rubric
Seven
Graded separately; Final Project Rubric
Final Project Rubric
Guidelines for Submission: This white paper should include a table of contents and sections that can be easily separated for each department area. It should be a
minimum of eight pages (in addition to the title page and references). The document should use 12-point Times New Roman font, double spacing, and one-inch
margins. Citations should be formatted according to APA style.
Critical Elements
Reimbursement and
the Revenue Cycle:
Reimbursement
Exemplary
Meets Proficient criteria and
includes any unique attributes of
this specific organization (100%)
Reimbursement and
the Revenue Cycle:
Revenue
Reimbursement and
the Revenue Cycle:
Prioritize
Meets Proficient criteria, and
prioritization demonstrates
nuanced insight into
departmental influence on the
revenue cycle (100%)
Departmental Impact
on Reimbursement:
Departments
Meets Proficient criteria and
communicates the impact in a
style that adheres to authentic
formatting for the business of
healthcare (100%)
Departmental Impact
on Reimbursement:
Activities
Meets Proficient criteria, and
assessment demonstrates keen
insight into the relationship
between departmental activities
and healthcare reimbursement
(100%)
Proficient
Comprehensively describes what
reimbursement means to this
specific healthcare organization
(85%)
Needs Improvement
Describes what reimbursement
means to a healthcare
organization, but description is
not comprehensive or is not
specific (55%)
Accurately illustrates the revenue Illustrates the revenue cycle using
cycle using a flowchart (100%)
a flowchart, but illustration is
inaccurate or incomplete (55%)
Prioritizes the departments at this
specific healthcare organization in
order of importance to the
revenue cycle, supporting
ordering of departments with
evidence (85%)
Prioritizes the departments at a
healthcare organization in order
of importance to the revenue
cycle but is not specific to this
healthcare organization or does
not include support for ordering
(55%)
Comprehensively describes the
Describes the impact of the
impact of the departments that
departments that influence
utilize reimbursement data at this reimbursement, but description is
healthcare organization that also not comprehensive or is not
influence reimbursement (85%)
specific to this healthcare
organization or to departments
that utilize reimbursement data
(55%)
Assesses the activities within each Assesses the activities within each
department at this healthcare
department at this healthcare
organization for how they may
organization but does not
impact reimbursement (85%)
explicitly link these activities to
reimbursement, or assessment is
not specific (55%)
Not Evident
Does not describe what
reimbursement means to a
specific healthcare organization
(0%)
Value
6.33
Does not illustrate the revenue
cycle using a flowchart (0%)
6.33
Does not prioritize the
departments at a healthcare
organization in order of
importance to the revenue cycle
(0%)
6.33
Does not describe the impact of
the departments at a healthcare
organization that influence
reimbursement (0%)
6.33
Does not assess the activities
within each department at a
healthcare organization for how
they may impact reimbursement
(0%)
6.33
Departmental Impact
on Reimbursement:
Responsible
Department
Correctly identifies the
department responsible for
ensuring compliance of billing and
coding policies and its impact on
reimbursement at this healthcare
organization (100%)
Identifies the department
responsible for ensuring
compliance of billing and coding
policies and its impact on
reimbursement at this healthcare
organization, but identification is
incorrect (55%)
Billing and
Meets Proficient criteria, and
Analyzes the collection of data by Analyzes the collection of data by
Reimbursement: Data analysis demonstrates a nuanced patient access personnel and its
patient access personnel and its
insight into the relationship
importance to the billing and
importance to the billing and
between patient access
collection process, including the
collection process but does not
personnels collection of data and importance of exceptional
include the importance of
the billing and collection process customer service (85%)
exceptional customer service
(100%)
(55%)
Billing and
Meets Proficient criteria, and
Analyzes how third-party policies Analyzes how third-party policies
Reimbursement: Third- analysis demonstrates a keen
would be used when developing would be used but does not apply
Party Policies
insight into the relationships
billing guidelines for PFS
analysis toward the development
between third-party policies,
personnel and administration
of billing guidelines for PFS
billing guidelines, and payer mix
when determining the payer mix personnel and administration or
(100%)
for maximum reimbursement
toward the determination of the
(85%)
payer mix for maximum
reimbursement (55%)
Billing and
Meets Proficient criteria, and
Organizes and explains the key
Organizes and explains the key
Reimbursement: Key explanation of key areas of review areas of review in order of
areas of review in order of
Areas of Review
demonstrates a nuanced insight
importance for timeliness and
importance for timeliness and
into reimbursement from thirdmaximization of reimbursement
maximization of reimbursement
party payers (100%)
from third-party payers (85%)
from third-party payers, but
explanation is cursory or illogical
(55%)
Billing and
Meets Proficient criteria and
Describes a way to structure
Describes a way to structure
Reimbursement:
demonstrates creativity in the
follow-up staff in terms of
follow-up staff in terms of
Structure
structure identified (100%)
effectiveness and explains
effectiveness but does not explain
rationale for effectiveness (85%) rationale for effectiveness (55%)
Billing and
Meets Proficient criteria and
Develops a plan for periodic
Develops a plan for periodic
Reimbursement: Plan demonstrates ingenuity in the
review of procedures to ensure
review of procedures to ensure
review process (100%)
compliance, including explicit
compliance but does not include
steps and the feasibility of
explicit steps or does not include
enacting the plan (85%)
the feasibility of enacting the plan
(55%)
Does not identify the department
responsible for ensuring
compliance of billing and coding
policies (0%)
6.33
Does not analyze the collection of
data by patient access personnel
(0%)
6.33
Does not analyze how third-party
policies would be used (0%)
6.33
Does not organize and explain the
key areas of review in order of
importance for timeliness and
maximization of reimbursement
from third-party payers (0%)
6.33
Does not describe a way to
structure follow-up staff in terms
of effectiveness (0%)
6.33
Does not develop a plan for
periodic review of procedures to
ensure compliance (0%)
6.33
Marketing and
Reimbursement:
Strategies
Marketing and
Reimbursement:
Communicate
Marketing and
Reimbursement:
Contracts
Marketing and
Reimbursement:
Compliance
Articulation of
Response
Meets Proficient criteria, and
research includes specific
examples applicable to
negotiation strategies (100%)
Meets Proficient criteria and
communicates this in a manner
that would be motivational for
the individual (100%)
Analyzes the strategies used to
negotiate new managed care
contracts, supporting analysis
with research (85%)
Communicates the important role
that each individual within this
healthcare organization plays with
regard to managed care contracts,
including the different types of
individuals within the
organization (85%)
Meets Proficient criteria and
Explains how new managed care
includes enough information to
contracts impact reimbursement
make informed decisions on
for the healthcare organization,
accepting the contract (100%)
including support for explanation
with concrete evidence or
research (85%)
Meets Proficient criteria and
Comprehensively discusses the
includes details such as how often resources needed to ensure
the resources should be updated billing and coding compliance
to stay current with regulations
with regulations and ethical
(100%)
standards (85%)
Submission is free of errors
Submission has no major errors
related to citations, grammar,
related to citations, grammar,
spelling, syntax, and organization spelling, syntax, or organization
and is presented in a professional (85%)
and easy to read format (100%)
Analyzes the strategies used to
negotiate new managed care
contracts but does not support
analysis with research (55%)
Communicates the important role
that each individual within this
healthcare organization plays with
regard to managed care contracts
but does not include the different
types of individuals within the
organization (55%)
Explains how new managed care
contracts impact reimbursement
for the healthcare organization
but does not include support for
explanation with concrete
evidence or research (55%)
Discusses the resources needed
to ensure billing and coding
compliance with regulations and
ethical standards, but discussion
is not comprehensive (55%)
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact readability
and articulation of main ideas
(55%)
Does not analyze the strategies
used to negotiate new managed
care contracts (0%)
6.33
Does not communicate the
important role that each
individual within this healthcare
organization plays with regard to
managed care contracts (0%)
6.33
Does not explain how new
managed care contracts impact
reimbursement for the healthcare
organization (0%)
6.33
Does not discuss the resources
needed to ensure billing and
coding compliance (0%)
6.33
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas (0%)
5.05
Earned Total
100%
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