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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 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 1 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: 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. 2 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. 3 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 Deliverable Draft of Reimbursement and the Revenue Cycle Draft of Billing, Marketing, and Reimbursement Final Project Submission: White Paper Module Due Grading Three Graded separately; Milestone One Rubric Five Graded separately; Milestone Two 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 oneinch margins. Citations should be formatted according to APA style. Critical Elements Reimbursement and the Revenue Cycle: Reimbursement Reimbursement and the Revenue Cycle: Flow of the Patient Exemplary Meets “Proficient” criteria and includes any unique attributes of this specific organization (100%) Proficient Comprehensively describes what reimbursement means to a healthcare organization (85%) Accurately illustrates the flow of the patient through the revenue cycle (100%) 4 Needs Improvement Describes what reimbursement means to a healthcare organization, but description is not comprehensive or is not specific (55%) Illustrates the flow of the patient through the revenue cycle, but illustration is unclear or inaccurate (55%) Not Evident Does not describe what reimbursement means to a healthcare organization (0%) Value 7.75 Does not illustrate the flow of the patient through the revenue cycle (0%) 7.75 Critical Elements Departmental Impact on Reimbursement: Departments Exemplary Meets “Proficient” criteria and describes the impact in a style that adheres to authentic formatting for the business of healthcare (100%) Proficient Comprehensively describes the impact of the departments that utilize reimbursement data and also influence reimbursement at a healthcare organization (85%) 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%) Departmental Impact on Reimbursement: Responsible Department Billing and Reimbursement: Third-Party Policies Billing and Reimbursement: Key Areas of Review Correctly identifies the department responsible for ensuring compliance of billing and coding policies and its impact on reimbursement at a healthcare organization (100%) Meets “Proficient” criteria, and analysis demonstrates a keen insight into the relationships between thirdparty 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%) Meets “Proficient” criteria, and explanation of key areas of review demonstrates a nuanced insight into reimbursement from thirdparty payers (100%) Organizes and explains the key areas of review in order of importance for timeliness and maximization of reimbursement from thirdparty payers (85%) 5 Needs Improvement 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%) 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%) 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%) 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%) Organizes and explains the key areas of review in order of importance for timeliness and maximization of reimbursement from thirdparty payers, but explanation is cursory or illogical (55%) Not Evident Does not describe the impact of the departments at a healthcare organization that influence reimbursement (0%) Value 7.75 Does not describe the activities within each department at a healthcare organization for how they may impact reimbursement (0%) Does not identify the department responsible for ensuring compliance of billing and coding policies (0%) 7.75 Does not analyze how thirdparty policies would be used (0%) 7.75 Does not organize and explain the key areas of review in order of importance for timeliness and maximization of reimbursement from thirdparty payers (0%) 7.75 7.75 Critical Elements Billing and Reimbursement: Structure Exemplary Meets “Proficient” criteria and demonstrates creativity in the structure identified (100%) Proficient Describes a way to structure follow-up staff in terms of effectiveness and explains rationale for effectiveness (85%) 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%) Marketing and Reimbursement: Contracts Meets “Proficient” criteria and includes enough information to make informed decisions on accepting the contract (100%) 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%) Explains how new managed care contracts impact reimbursement for the healthcare organization, including support for explanation with concrete evidence or research (85%) Comprehensively discusses the resources needed to ensure billing and coding compliance with regulations and ethical standards (85%) 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%) 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%) Articulation of Response Needs Improvement Describes a way to structure follow-up staff in terms of effectiveness but does not explain rationale for effectiveness (55%) 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%) 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%) Evaluates various strategies for ensuing stakeholders adhere to ethical standards during the process, but the analysis not supported with concrete evidence or research (55%) Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas (55%) Not Evident Does not describe a way to structure follow-up staff in terms of effectiveness (0%) Does not develop a plan for periodic review of procedures to ensure compliance (0%) 7.75 Does not explain how new managed care contracts impact reimbursement for the healthcare organization (0%) 7.75 Does not discuss the resources needed to ensure billing and coding compliance (0%) 7.75 Does not evaluate any strategies for ensuring stakeholders adhere to ethical standards during the process 7.75 Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas (0%) 7 Total 6 Value 7.75 100% 7 Running head: HCM 345 MILESTONE TWO 1 Draft of Billing, Marketing, and Reimbursement Denise Vazquez Southern New Hampshire University Billing and Reimbursement At this point, a patient’s view of a hospital is based on their initial encounter with the patient access team (PAT). Improved billing and collection efforts and an enhanced revenue cycle are made possible by having a “dynamite patient access team” (Hicks, 2019). An electronic medical record (EMR) can only be created after all of the patient’s demographic and Billing data has been collected. To maintain a high standard of patient care, the front end of the patient exchange must provide excellent customer service. Since the billing information will be used to support reimbursement claims, it’s critical that all relevant information, including contact information, be verified for correctness now. Government payers and private payers are the two types of third-party payers. Different regulations control each of them, and each carries a degree of risk. Due to the patient’s deductible, the private payer receives an additional reimbursement amount. In most circumstances, private insurers demand a co-payment. Government payers have a set sum for each treatment or operation, and they will only pay the agreed-upon fee. A section on thirdparty payers should be included in the process of creating billing rules, and it should consist of all of the most recent information on policy and pricing changes for each of the payers. Each payer has a varied turnaround time for payment, and knowing this might assist expedite reimbursement. There is no denying that government spending is lower than private-sector spending; therefore maximizing the payer mix requires ingenuity. To optimize reimbursement, Billing should begin by determining who can pay the quickest (Lagasse, 2016). Pre-registration/scheduling, pre-authorization, patient intake, coding, and Billing are all critical components of the revenue cycle. It’s essential to follow these steps to make the process of requesting reimbursements smoother. Verifying the information gathered from patients is the next step necessary in the reimbursement process. An insurance verification may inform you if you have to pay the copay or a deductible before going to the doctor. To help the revenue cycle, patient intake deals with up-front collection (copays/deductibles). After the appointment, patients are less inclined to pay, and a missed payment represents a revenue loss (Hicks, 2019). To avoid having to resubmit a claim because of a coding error or omission, a clean claim should be submitted at the time of service. Coding adheres to the insurance company’s billing regulations to eliminate the need for a resubmission. Reimbursement will be accomplished in a timely way if everything is done properly. People who don’t pay their bills aren’t the only ones to benefit from a collection department; it’s also used to follow up on claims. In terms of manpower and expertise, this department is well-equipped to do the work. For the department to follow, it will need to know how long to wait before contacting the payer. Refilling claims, how long to wait for interdepartmental changes and the time limit for doing so are some of the things to ask when calling an insurance company for claim updates or missing payments. Depending on the billing system, electronic claims are often sent in batches by date and may be printed out as a report. Claim information will be included in this report. The follow-up period is 10 days for claims submitted online and 15 days for claims mailed in. An electronic log will keep track of every claim that is followed up on, what actions were done, who was talked to about the claim, and any more follow-up that is necessary. The logs will be comprehensive, allowing anybody to see exactly what is going on at any given moment. This will clear up any lingering questions about the status of pending claims and assist to expedite payment. Supervisors and managers are in charge of making sure that all employees complete their tasks within the allotted timeframes. Managers will be able to monitor every employee’s work to ensure that they are fulfilling their responsibilities thanks to technological advancements. In order to keep a department working smoothly, compliance requires that everyone adhere to the company’s rules and regulations (Merritt, 2015). The patient’s private information is used by the billing department to get payment for medical services performed by a doctor. A quarterly evaluation of the department will be conducted with the help of a compliance officer. Listed below are the actions that will be taken: • Establish a compliance committee in your department • Provide training on the most recent regulatory changes • Create a method for tracking program results and evaluating its efficacy. • Assisting in the anonymous reporting of infractions • Reimbursement reports are submitted monthly. • Enforcement of sanctions against those who fail to adhere to the policy on compliance The strategy is viable because of the committee’s constant monitoring to emphasize any compliance concerns that may develop while correcting any errors to keep the team on track. The first thing to remember when negotiating a new managed care contract is that reimbursement is crucial, but it isn’t the most critical component of the discussion. Before agreeing to a new contract, there are additional things to consider. When getting into a contract, it’s important to keep the following things in mind: • Avoid focusing on rates. • Aims should always be in the future. • It’s essential to have a willingness to compromise Being aware about the payer’s business practices helps to divert attention away from rates. Make sure to find out how quickly or slowly they pay back their customers and if they give incentives, products, or services. The best course of action is to look for a payer with a wide range of product offerings. Selecting a payer who is willing to sign a long-term contract helps keep objectives in focus. The payer’s stable money stream will benefit the organization in the long run. Contractual agreements must always start with a clear understanding of what each party hopes to achieve. Managed care contracts need compromise since both parties have a vision of how the talks should go. Both parties must have patience throughout these proceedings since not all requests will be granted; in fact, certain requests will simply not work (Krohn, 2017). Good negotiations ensure that both sides go away happy. Marketing and Reimbursement Contracts for managed care have an impact on a number of different parts of the healthcare system. Physicians are impacted because it affects the amount of compensation they get for their services. As a physician, you must find a way to be an advocate for your patients while still working for the insurance company. Any out-of-pocket expenses a patient has are based on the billed rate of service they get. As soon as an agreement has been reached, management employees are in charge of handling the paperwork and ensuring that patients get appropriate treatment (Cocke,2017). Using the agreed-upon rates, Billing files the claims Once a contract has been signed and put into effect, all parties are held legally liable for their respective parts of it. Everyone concerned must make sure that the agreement is carried out in accordance with the document that was signed by all parties. Better coordination of treatment in managed care results in happier patients. About 30% of Rockford Health Systems’ income comes from managed care, according to Paula Dillion, the organization’s director (Gruessner, n.d.). An organization’s income and reimbursements will be affected by the agreed rates and payer mix it has in place. To optimize reimbursements and payments, good managed care agreements will provide more products that allow for better payouts and more goods. There are procedures that must be followed in order to keep invoicing and coding in line with industry standards. There needs to be oversite, leadership, risk assessment, communication, training and a standard of control. • Supervisors and managers are leaders. • It is the responsibility of information technology (IT) staff to conduct risk assessments to determine if the system is vulnerable to fraud. • Communication is the ability to disclose abuse without fear of retribution. • In the event of numerous mistakes, employees may need to be retrained. • Standard of Control is enforcing a punishment policy for individuals who flout the rules. Because rules, regulations, and laws control compliance, this is a significant matter. Those who work in the Billing and coding department have a moral and legal obligation to ensure that the organization and its patients are not harmed by their actions. As a result, if these guidelines are not followed or someone is operating outside of compliance, the hospital might be fined, terminated, or lose income. References Cocke, A. (2017, July 5). What is Hospital Administration. Retrieved from https://careertrend.com/about-5489253-duties-responsibilities-hospitaladministrator.html Gruessner, V. (n.d.). Heath Payer Tips For Negotiating Managed Care Contracts. Retrieved from https://healthpayerintelligence.com/news/health-payer-tips-for-negotiatingmanaged-carecontracts Hicks, J. (2019, August 06). 5 Ways to Maximize Insurance Reimbursements. Retrieved from https://www.verywellhealth.com/maximizing-insurance-reimbursements-2317567 Krohn, S. (2017, April 18). Successfully Negotiating Managed Care Contracts. Retrieved from https://medium.com/@stevekrohn/successfully-negotiating-managed-carecontracts792b06ed7695 Lagasse, J. (2016, May 06). Hospitals work to fine-tune payer mixes, but finding saving is no easy task. Retrieved from https://www.healthcarefinancenews.com/news/hospitalsworkfine-tune-payer-mixes-finding-savings-no-easy-task Merritt, M. (2015, February 15). ABC’s of Healthcare Corporate Compliance Programs. Retrieved from https://www.physicianspractice.com/blog/abcs-healthcare-corporatecompliance-programs Running head: PAYMENT SYSTEMS 1 Billing and Coding Denise Vazquez Southern New Hampshire University PAYMENT SYSTEMS 2 Introduction For a healthcare facility to operate appropriately, it must adhere to government laws and directives. These rules impact every element of healthcare, but billing and coding, in particular, are very sensitive. In addition, healthcare providers must be aware of their part in reimbursement. It is the responsibility of service providers to guarantee that all applicable laws and policies are complied with. Healthcare professionals/providers must verify that the agreement they have with the third-party payers offering reimbursement service for the company is met. Various billing and coding regulations, how they affect reimbursement in healthcare, their impact on operations For the sake of the patients’ safety and the provision of legal health care, billing and coding laws are established and enforced. The Health Insurance Portability and Accountability Act (HIPPA) will affect every element of healthcare. For “all health plans, healthcare clearinghouses, and to any healthcare providers who transmit health information and data in connection with transactions,” to include financial and administrative transactions,” for which the Secretary of HHS has adopted standards under HIPAA,” this act applies particular coding and billing provisions (HHS, 2017). Health insurance companies, government agencies like the Centers for Medicare and Medicaid Services (CMS), and other organizations that offer services or goods to patients were all required under HIPAA to use a uniform electronic data exchange format. Electronic health care transactions must utilize the same health care code sets, IDs, and code sets for all parties participating in these exchanges under HIPAA (HHS, 2017). The Diagnosis Related Groups are PAYMENT SYSTEMS 3 used by the Prospective Payment Systems (PPS) to compensate the hospitals (DRGs). Thirdparty payers, healthcare providers, coding and data, and the software used to enter data all play a role in determining reimbursement (Harrington, 2016). To get the full DRG payment, documentation must contain the patient’s medical history and symptoms at the time of admission. As a whole, PPS moves the burden of profit or loss from the insurance company to the health care provider. For the health care institution to generate a profit depending on averages and classify patients into comparable groups, it must now manage care to provide the most incredible quality of treatment feasible. Another piece of legislation that impacts health care reimbursement is the Affordable Care Act (ACA). The Affordable Care Act (ACA) was adopted in March 2010 as a health care reform law with three main objectives. All Americans should have access to affordable health insurance. The Medicaid program should be expanded for low-income individuals, and innovative medical treatment should be supported to reduce health care costs (U.S. Department of Health and Human Services). As part of the Affordable Care Act (ACA), the government is committed to transitioning health care from a volume-based payment system to a quality-based reimbursement system. Patients grew in the 1980s as health insurance became more inexpensive and simpler to get due to Medicare’s transition to the PPS system. Sadly, significant occurrences like surgery, trauma, and hospital hospitalizations were not reimbursed at the same rate as more minor incidents (MedicalBillingAndCoding.org., 2017). The healthcare business was feeling the effects of this. A primary care business grew under the Affordable Care Act because of the ACA’s emphasis on promoting primary care doctors and medical facilities. PAYMENT SYSTEMS 4 Conclusion Because of the Affordable Care Act, coding and billing requirements will change. Items and services that are essential for treatment and are integrated for billing are known as packaging. As part of the Hospital Outpatient Prospective Payment Systems, coding employees must grasp packaging and its purpose (OPPS). It is possible to perform so many different types of packing that some products will not be paid if they are done wrong. Wrongly coded services may add up quickly, placing an enormous financial strain on a business. PAYMENT SYSTEMS 5 References Harrington, Michael K. (2016). Healthcare Finance: Revenue Cycle Management. Burlington: Jones & Bartlett Learning HHS. (2017). Summary of HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/forprofessionals/privacy/laws-regulations/ MedicalBillingAndCoding.org. (2017) Understanding the Affordable Care Act & HIPPA. Retrieved from http://www.medicalbillingandcoding.org/healthinsuranceguide/affordable-care-act/ U.S. Department of Health and Human Services. Affordable Care Act (ACA). Retrieved from https://www.healthcare.gov/glossary/affordable-care-act/
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