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.
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