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 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.
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 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:
- 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 were received for those 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 the payment is collected
- Departmental Impact on Reimbursement
- 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-for performance incentives.
- Describe the activities within each department in a healthcare organization for how they may impact reimbursement. What specific data would you review 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 on reimbursement in a healthcare organization?
- Billing and Reimbursement
- 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?
- 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.
- 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 plan within this organization.
- Marketing and Reimbursement
- Explain how new managed care contractsimpact reimbursement for the healthcare organization. Support your explanation with concrete evidence
or research. - Discuss the resources needed to ensure billing and coding compliance with regulations.
- Evaluate strategies to ensure stakeholders involved in the reimbursement process adhere to ethical standards
- Explain how new managed care contractsimpact reimbursement for the healthcare organization. Support your explanation with concrete evidence
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. It should reflect the incorporation of feedback gained throughout the course. This submission will be graded using the Final Project Rubric.
What to Submit
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.
Final Project Rubric
| Criteria | Exemplary | Proficient | Needs Improvement | Not Evident | Value |
|---|---|---|---|---|---|
| Reimbursement and the Revenue Cycle: Reimbursement | Meets “Proficient” criteria and includes any unique attributes of this specific organization (100%) | Comprehensively describes what reimbursement means to a healthcare organization (85%) | Describes what reimbursement means to a healthcare organization, but description is not comprehensive or is not specific (55%) | Does not describe what reimbursement means to a healthcare organization (0%) | 7.75 |
| Reimbursement and the Revenue Cycle: Flow of the Patient | N/A | Accurately illustrates the flow of the patient through the revenue cycle (100%) | Illustrates the flow of the patient through the revenue cycle, but illustration is unclear or inaccurate (55%) | Does not illustrate the flow of the patient through the revenue cycle (0%) | 7.75 |
| Departmental Impact on Reimbursement: Departments | Meets “Proficient” criteria and describes the impact in a style that adheres to authentic formatting for the business of healthcare (100%) | Comprehensively describes the impact of the departments that utilize reimbursement data and also influence reimbursement at a healthcare organization (85%) | Describes the impact of the departments that influence reimbursement, but description is not comprehensive or is not specific to a healthcare organization or to departments that utilize reimbursement data (55%) | Does not describe the impact of the departments at a healthcare organization that influence reimbursement (0%) | 7.75 |
| Departmental Impact on Reimbursement: Activities | Meets “Proficient” criteria, and effectively describes the relationship between departmental activities and healthcare reimbursement (100%) | Describes the activities within each department at a healthcare organization for how they may impact reimbursement (85%) | Describes the activities within each department at a healthcare organization but does not explicitly link these activities to reimbursement, or assessment is not specific (55%) | Does not describe the activities within each department at a healthcare organization for how they may impact reimbursement (0%) | 7.75 |
| Departmental Impact on Reimbursement: Responsible Department | N/A | Correctly identifies the department responsible for ensuring compliance of billing and coding policies and its impact on reimbursement at a healthcare organization (100%) | Identifies the department responsible for ensuring compliance of billing and coding policies and its impact on reimbursement at a healthcare organization, but identification is incorrect (55%) | Does not identify the department responsible for ensuring compliance of billing and coding policies (0%) | 7.75 |
| Billing and Reimbursement: Third-Party Policies | Meets “Proficient” criteria, and analysis demonstrates a keen insight into the relationships between third party policies, billing guidelines, and payer mix (100%) | Analyzes how third-party policies would be used when developing billing guidelines for PFS personnel and administration when determining the payer mix for maximum reimbursement (85%) | Analyzes how third-party policies would be used but does not apply analysis toward the development of billing guidelines for PFS personnel and administration or toward the determination of the payer mix for maximum reimbursement (55%) | Does not analyze how third party policies would be used (0%) | 7.75 |
| Billing and Reimbursement: Key Areas of Review | Meets “Proficient” criteria, and explanation of key areas of review demonstrates a nuanced insight into reimbursement from third party payers (100%) | Organizes and explains the key areas of review in order of importance for timeliness and maximization of reimbursement from third party payers (85%) | Organizes and explains the key areas of review in order of importance for timeliness and maximization of reimbursement from third party payers, but explanation is cursory or illogical (55%) | 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%) | 7.75 |
| Billing and Reimbursement: Structure | Meets “Proficient” criteria and demonstrates creativity in the structure identified (100%) | Describes a way to structure follow-up staff in terms of effectiveness and explains rationale for effectiveness (85%) | Describes a way to structure follow-up staff in terms of effectiveness but does not explain rationale for effectiveness (55%) | Does not describe a way to structure follow-up staff in terms of effectiveness (0%) | 7.75 |
| Billing and Reimbursement: Plan | Meets “Proficient” criteria and demonstrates ingenuity in the review process (100%) | Develops a plan for periodic review of procedures to ensure compliance, including explicit steps and the feasibility of enacting the plan (85%) | Develops a plan for periodic review of procedures to ensure compliance but does not include explicit steps or does not include the feasibility of enacting the plan (55%) | Does not develop a plan for periodic review of procedures to ensure compliance (0%) | 7.75 |
| Marketing and Reimbursement: Contracts | Meets “Proficient” criteria and includes enough information to make informed decisions on accepting the contract (100%) | Explains how new managed care contracts impact reimbursement for the healthcare organization, including support for explanation with concrete evidence or research (85%) | 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%) | Does not explain how new managed care contracts impact reimbursement for the healthcare organization (0%) | 7.75 |
| Marketing and Reimbursement: Compliance | Meets “Proficient” criteria and includes details such as how often the resources should be updated to stay current with regulations (100%) | Comprehensively discusses the resources needed to ensure billing and coding compliance with regulations and ethical standards (85%) | Discusses the resources needed to ensure billing and coding compliance with regulations and ethical standards, but discussion is not comprehensive (55%) | Does not discuss the resources needed to ensure billing and coding compliance (0%) | 7.75 |
| Marketing and Reimbursement: Ethical Standards | Meets “Proficient” criteria and includes details such as how strategies impact various stakeholder groups (100%) | Thoroughly evaluates various strategies for ensuring stakeholders adhere to ethical standards during the process (85%) | Evaluates various strategies for ensuing stakeholders adhere to ethical standards during the process, but the analysis not supported with concrete evidence or research (55%) | Does not evaluate any strategies for ensuring stakeholders adhere to ethical standards during the process | 7.75 |
| Articulation of Response | Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy to read format (100%) | Submission has no major errors related to citations, grammar, spelling, syntax, or organization (85%) | Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas (55%) | Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas (0%) | 7 |
