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Homework answers / question archive / HCM 345 Final Project Guidelines and Rubric Overview The final project for this course is the creation of a white paper

HCM 345 Final Project Guidelines and Rubric Overview The final project for this course is the creation of a white paper

Management

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 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. 1 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 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. II. Departmental Impact on Reimbursement A. Describe the impact of the departments in a 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. 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? 2 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 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. 3 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 Departmental Impact on Reimbursement: Departments Departmental Impact on Reimbursement: Activities 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%) Meets “Proficient” criteria and communicates 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%) Meets “Proficient” criteria, and assessment demonstrates keen insight into the relationship between departmental activities and healthcare reimbursement (100%) Assesses the activities within each department at a healthcare organization for how they may impact reimbursement (85%) 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%) 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%) Assesses the activities within each department at a healthcare organization but does not explicitly link these activities to reimbursement, or assessment is not specific (55%) Not Evident Does not describe what reimbursement means to a healthcare organization (0%) Value 6.75 Does not illustrate the flow of the patient through the revenue cycle (0%) 6.75 Does not describe the impact of the departments at a healthcare organization that influence reimbursement (0%) 6.75 Does not assess the activities within each department at a healthcare organization for how they may impact reimbursement (0%) 6.75 Critical Elements Departmental Impact on Reimbursement: Responsible Department Exemplary Proficient Correctly identifies the department responsible for ensuring compliance of billing and coding policies and its impact on reimbursement at a healthcare organization (100%) Billing and Reimbursement: Data Meets “Proficient” criteria, and analysis demonstrates a nuanced insight into the relationship between patient access personnel’s collection of data and the billing and collection process (100%) Meets “Proficient” criteria, and analysis demonstrates a keen insight into the relationships between thirdparty policies, billing guidelines, and payer mix (100%) Analyzes the collection of data by patient access personnel and its importance to the billing and collection process, including the importance of exceptional customer service (85%) Billing and Reimbursement: Key Areas of Review 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%) 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%) Billing and Reimbursement: Third-Party Policies 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%) 5 Needs Improvement 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 the collection of data by patient access personnel and its importance to the billing and collection process but does not include the importance of exceptional customer service (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%) Describes a way to structure follow-up staff in terms of effectiveness but does not explain rationale for effectiveness (55%) Not Evident Does not identify the department responsible for ensuring compliance of billing and coding policies (0%) Value 6.75 Does not analyze the collection of data by patient access personnel (0%) 6.75 Does not analyze how thirdparty policies would be used (0%) 6.75 Does not organize and explain the key areas of review in order of importance for timeliness and maximization of reimbursement from thirdparty payers (0%) Does not describe a way to structure follow-up staff in terms of effectiveness (0%) 6.75 6.75 Critical Elements Billing and Reimbursement: Plan Exemplary Meets “Proficient” criteria and demonstrates ingenuity in the review process (100%) Proficient 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: Strategies 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%) 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%) 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%) Marketing and Reimbursement: Communicate Submission has no major errors related to citations, grammar, spelling, syntax, or organization (85%) Needs Improvement 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%) 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%) Not Evident Does not develop a plan for periodic review of procedures to ensure compliance (0%) Value 6.75 Does not analyze the strategies used to negotiate new managed care contracts (0%) Does not communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts (0%) 6.75 Does not explain how new managed care contracts impact reimbursement for the healthcare organization (0%) 6.75 Does not discuss the resources needed to ensure billing and coding compliance (0%) 6.75 Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas (0%) 5.5 Total 6 6.75 100% Running head: HEALTHCARE REIMBURSEMENT 5-2 Final Project Milestone Two: Draft of Billing, Marketing, and Reimbursement HCM-345-X5039 Healthcare Reimbursement 21EW5 Tracy McNeill Southern New Hampshire University May 18TH2021 Professor Annette Webster 1 HEALTHCARE REIMBURSEMENT 2 Healthcare Reimbursement (Final Project Milestone Two) Introduction Healthcare systems need to understand and value the patient's contributions in developing and maintaining healthcare revenue. The hospital's departments have policies that govern most interactions and plans to ensure adequate care is catered for patients'. The necessity of the financial cycle in healthcare systems assures keeping track and monitoring expenditures in the organizations. Managers have to stay close to the responsible individuals, for example, the patient finance service who receives diverse payments and helps in feeding the client's account in a medical context. Recording, keeping, and updating the account status is also significant to healthcare providers and patients for clarity on medical expenses. The assignment features the revenue cycle and reimbursements in healthcare facilities with detailed explanations. Reimbursement Reimbursement allows business proprietors to pay back their workers who have spent money to cater to business-related expenses. Most business organizations have acknowledged the compensation process to cater to workers' essential needs. In healthcare systems, reimbursement is defined as the healthcare provider's expense, medical experts, or hospital collects after medical service. The payment is not necessarily in monetary terms directly from the client but the government (Torrey, 2020). Insurance companies have also catered for medical expenses after patients get diagnosed, and service providers apply for reimbursements. HEALTHCARE REIMBURSEMENT 3 A. In healthcare systems, revenue cycles involve processes and methods to ensure precise payment entitlements and appropriate billing. It entails all functions made right from when a patient enters the facility to the time of billing. Representatives from essential departments, such as registrations, health information, staff developers, and patient accounts, participate in revenue cycles. The clients must first encounter registration employees, cover verifications, clinicians encounter, health records, medical coding, entry of charges, charge transmission, and QR calling. The employee's details get recorded at the inpatient admission department. The data collections involve higher integrity with verifications of insurance cover. Referrals are also acquired and pre-authorization for selected medical procedures. Next, the patients' medical proof with financial liability gets recorded for accuracy; the departments of health information record clinical credentials with appropriate coding. The process later follows to the patient account section for billing. Healthcare facilities will then expect payment to get channeled in healthcare accounts within 45 days. HEALTHCARE REIMBURSEMENT 4 The importance of keeping excellent customer care service offers an incredible value to the medical facility. The facility should consider building its value through quality care provision, responding to clients' queries appropriately, and attending to patients at the right time to maintain a healthy reputation (Valerius, Bayes, Newby, & Blochowiak, 2018). Health facilities also retain customers by creating a suitable environment for patient experience. Retaining customers should be a priority and gets relatively cheaper compared to attracting new patients. When patients' preferences get valued and gratified with medical care, they become part of the health facility and always recommend friends and relatives to your services. Furthermore, excellent customer delivery improves clinician involvement in improvement projects that gauge the facility's development. HEALTHCARE REIMBURSEMENT 5 B. Third-party health insurance is insurance policies owned by small organizations buy to cover their operations and employees. The insurance company is expected to cater to the patient's care and related bills directly with administration assistance (DeMerceau, 2019). Healthcare facilities depend on the third-party insurer for clearing dues during financial processing for specific patients. During the development of billing strategies, third-party insurance gets significant in processing claims that will provide essential information, the authenticity of the data acquired, and validation of the patients' data records. The company will then reimburse the funds directly to the service provider or portions per the policy guidelines. The policy will also ensure the organization works within the specified law that governs its operations effectively and comply with the state laws. The health care providers will have no room for violations or create an upsurge in charges without clear communications to the third-party agency. C. Appropriate timeliness and increase of reimbursement for third-party payers determine the effectiveness of payment plans in healthcare facilities. The administration should have accurate patient information clearly stated, use suitable equipment, understand the patient's obligation, verify the patient's preference to compensation, and finance collection before diagnosing. The collection of accurate information prevents the likelihood of time wastage in re-examining data collected and reducing claims refuted. Bias information will also extend the costly period in the reimbursement sequence. Eligible tools and resources used will determine if the patient is an insurance holder and the possibility of deductions and co-remittances that affect the indemnity owner's history. The patient must also be able to view personal expenditures on their own. The patient's accessibility to financial plans will create better knowledge of their financial responsibilities. The hospital will determine what the patient can afford through close HEALTHCARE REIMBURSEMENT 6 examination of the patient's payment ability. The system allows repayment plans, hence the need for money collection before healthcare provision. D. Follow-up staff is essential in determining the care system's effectiveness when evaluating the patient's health conditions. For the efficiency of the diagnosis process, health care providers will have to evaluate the effectiveness of the treatment method through follow-ups. The excellent way to make real progress in healthcare systems is through follow-up calls. The hospital has to make precise records of the call for references and patients' queries. For call efficiency, the management will have to document detailed information with call tries, the patient's health status, the patients' health problems with medicines, details on appointments, postdischarge actions, and follow-ups (AHRQ, n.d.). Follow-up calls have significance in assessing the health status to check medication for patients and clarify the patients. The record can get obtained for clarification purposes or to identify the likelihood of further health complications. E. Health care organizations require the evaluation of healthcare programs regularly to identify challenges associated with service delivery. The service provider has to comply with various enactment from the ministries and health administrators. The national law review advocate for the following steps for an operative compliance program (National Law Review, 2020). the steps are as follows; Implementation of the policies, procedures, and standard conduct. Concerning the job designed for, the policies, morals, and procedures should get written precisely. Therefore, understanding the information should get easy when reading. HEALTHCARE REIMBURSEMENT 7 Defining compliance committee or officer Setting up a compliance panel will help in detecting and correcting the issues against the organizational policies. In addition, the committee will address issues appropriately and communicate non-compliance. Education and training Training will involve having conferences and reading compliance-related articles. In addition, the organization must be able to address training as a job requirement. Effective communication Communication aids in reporting non-compliance within the organization; communication channels should be reliable, such as using a hotline. In addition, the communication should entail features such as getting approachable, confidentiality in a message, and accurate response. Monitoring and auditing Risks can get determined through monitoring and auditing by using a yearly work plan. The plan will evaluate organizational compliances and noncompliances by assessing the reports. Disciplinary guidelines Disciplinary rules should get published with a clear standard to be followed by team members. Regular inspection will also determine whether there are violations of guidelines or not. Offense detection and corrective action Identifying offenses within the organization and provision of the corrective plan indicates the effectiveness of the program in handling non-compliances. HEALTHCARE REIMBURSEMENT 8 IV. A. Healthcare systems have engaged in mutual contract systems to improve the financial performances of the organization. Such consultations have increased payments and improved the revenue cycle of the healthcare systems. The relationship with the payer is significant during such negotiations to keep a good reputation. At first, an assessment of the situation is done. The organizations must identify changes, investments, and the perception of the system. Examination proves identification of organizations market, performance, and management of cares performance aids in positive contacts. Based on the research on successful situation assessment, the organization must consider the development strategy (Tailor, n.d.). In healthcare systems, negotiations on healthcare pricing, time frames for contracts, and expectations in rate increase get determined. The final step is to conduct the new contract negotiations. Identification of necessary stakeholders is made. B. Health care stakeholders have different roles to play in managing the healthcare systems. Based on the care contracts, all personnel incurs financial risks in the organizations. The finance manager, policy provider, healthcare clinicians, and managed care staff have a significant role in healthcare in determining the success of contracts (Pizzo & Ryan, 2017). The managed care staff is responsible for running the healthcare data for the identification of health plan data. The revenue cycle staff will also assess the contractual pay, a plea for contractual guidelines. The credentialing team will create timelines and the process necessities for credentialing. C. Managed care aims at providing a comprehensive structure and emphasis on controlling the cost of healthcare (Case Management Study Guide, 2017). The care contracts management rearranges the effectiveness of reimbursement between payers and service providers. In a managed care contract, repayment is held to healthcare HEALTHCARE REIMBURSEMENT 9 outcomes and the quality of care provided. Managed care systems used value-centered care to reduce costs while improving the quality of services to patients. The agreement affects the significance of reimbursements under the fee-for-service (MACPAC, 2020). Recompense takes place for specified services provided to covered persons. The difference between managed care payer contracts and fee-forservice in reimbursement is that it contains care dispenses risks between payor and provider for benefactors. D. In healthcare systems, billers and coders are experts accountable for processing health insurance claims for healthcare facilities. For accuracy, the tools used should have ethical regulations. Another resource to effectively create change and improve healthcare provision is using a surgical modifier, which increases reimbursements. The auditors play a significant role in performing internal audits to review medical billing and processes. Without proper editing, the hospital will fail to identify the great risked concerned area and identify workflow inadequacies (RevCycleIntelligence, 2020). Failure to comply with regulations per ethical orders can easily result in losses in healthcare organizations. The inspectors must also avoid loss of life from unsatisfactory due to a delay or no auditing programs. Conclusion Managers have to stay close to the responsible individuals, for example, the patient finance service who receives diverse payments and helps in feeding the client's account in a medical context. .Insurance companies have also catered for medical expenses after patients get diagnosed, and service providers apply for reimbursements. The health care providers will have no room for violations or create an upsurge in charges without clear communications to the third-party agency. The system allows repayment plans, hence the need for money HEALTHCARE REIMBURSEMENT 10 collection before healthcare provision. Follow-up calls have significance in assessing the health status to check medication for patients and clarify the patients. The record can get obtained for clarification purposes or to identify the likelihood of further health complications. The credentialing team will create timelines and the process necessities for the credential process. HEALTHCARE REIMBURSEMENT 11 References AHRQ. (n.d.). Tool 5: How to conduct a postdischarge Follow-up phone call. Agency for Healthcare Research and Quality. Retrieved June 3, 2021, from https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html Case Management Study Guide. (2017). Managed care concepts and rules for reimbursement. Case Management Study Guide. Retrieved June 3, 2021, from https://casemanagementstudyguide.com/ccm-knowledge-domains/healthcarereimbursement/managed-care-concepts-and-rules-for-reimbursement/ DeMerceau, J. (2019). Define third-party health insurance. Small Business - Chron.com. Retrieved June 3, 2021, from https://smallbusiness.chron.com/define-thirdpartyhealth-insurance-43641.html MACPAC. (2020). Managed care's effect on outcomes : MACPAC. MACPAC. Retrieved June 3, 2021, from https://www.macpac.gov/subtopic/managed-cares-effect-onoutcomes/ National Law Review. (2020). Seven elements of an effective compliance program. The National Law Review. Retrieved June 3, 2021, from https://www.natlawreview.com/article/seven-elements-effective-compliance-program Pizzo, J. J., & Ryan, D. L. (2017). 6 practices for effective managed care contracting. hfma. Retrieved June 3, 2021, from https://www.hfma.org/topics/article/56183.html RevCycleIntelligence. (2020). 5 key ways to ensure hospital compliance program consistency. RevCycleIntelligence. Retrieved June 3, 2021, from https://revcycleintelligence.com/news/5-key-ways-to-ensure-hospitalcompliance-program-consistency Tailor, A. (n.d.). ECG | A plan and guideline for managed care contracting negotiations. ECG Management Consultants. Retrieved June 3, 2021, from HEALTHCARE REIMBURSEMENT 12 https://www.ecgmc.com/thought-leadership/articles/a-plan-and-guideline-formanaged-care-contracting-negotiations Torrey, T. (2020). How healthcare providers are paid by reimbursement. Verywell Health. Retrieved June 3, 2021, from https://www.verywellhealth.com/reimbursement2615205 Valerius, J. D., Bayes, N. L., Newby, C., & Blochowiak, A. L. (2018). a revenue cycle process approach. Cloud Object Storage | Store & Retrieve Data Anywhere | Amazon Simple Storage Service (S3). Retrieved June 3, 2021, from https://s3.amazonaws.com/ecommerceprod.mheducation.com/unitas/highered/sample-chapters/9781259608551.pdf Running head: REIMBURSEMENT AND THE REVENUE CYCLE Reimbursement and the Revenue Cycle HCM-345-X5039 Healthcare Reimbursement 21EW5 Tracy McNeill Southern New Hampshire University May 18TH2021 Professor Annette Webster 1 REIMBURSEMENT AND THE REVENUE CYCLE 2 Reimbursement and the Revenue Cycle What Reimbursement Means to a Healthcare Organization A reimbursement is an essential act in a healthcare organization. It refers to the payment made to a hospital, pharmacies, and other healthcare organizations after offering various medical services (Lin et al., 2020). Hospitals and other healthcare organizations provide different medical services to their patients. They diagnose patients and treat them whenever they are sick. In return, the patient pays the hospital in return as an appreciation for the services offered. While the patient covers the reimbursement sometimes, in other cases, the government or the insurance company covers such expenses. The insurance company can either cover the entire cost of the patient or partially pay for it, depending on the patient's insurance plan. When the insurance company or the government pays for medical services offered, they reimburse the hospital. After a patient receives medical services, they pay the hospitals in cheque or other methods. The reimbursement offered by the insurance companies is intended to help patients cover the extra costs that may apply in healthcare provision. Different private companies provide insurance services to help their patients in times of need. Generally, after the medical provider offers the medical assistance to the patient, they send the medical costs to the insurer or the people concerned with paying the medical expenses. Once the hospital or healthcare provider sends the bill, the insurance company, in turn, covers the bill and reimburses the hospital. In some hospitals in the United States, there are specific arrangements made to help their employers. Such arrangements intended to help the employers are referred to as the Health reimbursement arrangements. Such arrangements work to cover their hospital expenses REIMBURSEMENT AND THE REVENUE CYCLE 3 whenever they spend their own money covering their medical costs (Shneider, 2020). Health insurance arrangements are offered by employers who in turn benefit from such arrangements. What Would Happen If Hospitals offered Medical Services but were not Paid Reimbursements are essential for the running of the hospitals. The reimbursements made to the hospitals and other health service providers keep them afloat by being able to cover their expenses. Hospitals, just like other organizations, have different expenses to cover. Some of the hospitals' expenses cover the costs for the medical equipment in the hospitals. They also pay for the pharmaceuticals and medicines that the hospitals use to treat people. Another expense that the hospitals cover from the reimbursements is paying some of the government's employees. If the hospitals offered medical services to the patients and the patients could not pay for the medical expenses, the hospitals would not be able to cater to their expenses. If the hospitals cannot cater to their expenses, the people who rely on the hospitals for survival would be left to suffer. First and foremost, the different employees paid by the hospitals would not be paid, and the people who rely on them would suffer. This is because the employees have people who depend on them, and if they are not paid, the people who are dependent on them will suffer. Also, hospitals are essentials in every society because they offer medical services to sick people. Whenever people are suffering, they visit the hospitals seeking help. If the hospitals are not paid after providing medical services, they would not be able to keep up with the various needs of the patients, such as medicine and equipment. As a result, the patients who rely on the hospitals for medical help would be in trouble; hence diseases and mortality rates would increase. REIMBURSEMENT AND THE REVENUE CYCLE 4 The Flow of Patient Cycle The revenue cycle of the patient is a long process beginning at the first time when the patient plans to visit a healthcare facility and makes a prior appointment. In making the appointments, the patients visit the hospitals and talks to administrators about the insurance services, eligibility, and creating a patient account in the hospital (RevCycleIntelligence, 2019). The patient accounts contain the patient's relevant information, including their medical history of sickness and whether they use health insurance cover. All the correct details of the patients must be taken in the revenue cycle because they are used in making financial decisions. After making such arrangements, the patient receives medical assistance from the hospitals, after which the hospitals make the submission of a claim. This involves noting the nature of treatments or medical services received at the hospital using some special codes (NueMD, 2018). the codes show the specific treatments provided and are used in making reimbursements for the offered treatments. After the hospitals make claims, they send the claims to the relevant insurance provider, making necessary reimbursements. The insurance company evaluates the information and looks at their terms with the given patient. If the claim meets their requirements, they make the payments required to the hospitals. On some occasions, however, the insurance company may fail to pay the hospital. This happens when mistakes are made in filing a claim. It may occur due to wrong coding and missing the patient details in the insurance claim. Provider coding Hospital Front Desk Billing Department REIMBURSEMENT AND THE REVENUE CYCLE 5 Departmental Impact Reimbursement Departments serve integral roles in the provision of healthcare. There are different departments in an organization that serve different roles for the benefit of the organization. In a hospital, for instance, the departments serve crucial roles in the running of the hospital. Since the hospital's primary goal is to improve the health status of different people, they are divided into various departments to increase service delivery. Departments in hospitals are essential in the hospitals because they improve efficiency and resilience in healthcare provision (Abimbola et al., 2019). The departments enhance the efficiency in the hospital by creating decentralization; hence people work in different areas where they perform best. As a result, people specified in finance can work in the finance office while others specializing in pharmacy can work in the hospital's pharmacy. This leads to increased service delivery to patients because everyone works in areas where they are comfortable. Therefore, the departments make it easier for the organizations that use reimbursement data to find the correct details of the patients and make it faster, thus improving workflow in the organization. Since the departments are all parts of the organization, an internal audit would be preferable in determining whether the reimbursement impact has reached its full potential. Internal audit refers to the internal evaluation of the organization's resources and governance by looking at the accounting processes in the various departments (Van Gelderen et al., 2017). It is an essential step in hospitals because it ensures that there is transparency in the departments. The impact of these departments on a pay for performance can be measured by looking at how the different departments incorporate in the working of the hospital organization. REIMBURSEMENT AND THE REVENUE CYCLE 6 Activities Within Each Department and how they Impact Reimbursements All the activities carried out in the departments affect reimbursements in the departments in one way or the other. If there are harmful practices in the departments, the reimbursement is likely to be negatively affected. Practices like corruption and misinterpretation of data in the department are likely to affect the data given out. As a result, private insurance companies may decline to pay for insurance claims. This, in turn, would reduce the amount of money reimbursed to the hospital and, consequently, its departments. To make changes in reimbursement processes, it would be necessary to review the data from the hospital's integral departments. This would prove essential in understanding what every department needs to improve on and what to maintain. Responsible Department for ensuring compliance with Billing and Coding policies Compliance in healthcare refers to following the rules set up by the organization and the entire healthcare fraternity. The billing and coding policies in healthcare are intended to ensure transparency by preventing graft and corruption cases in the hospital. The department responsible for ensuring compliance with billing and coding policies is the Joint office for compliance, also called the JOC (The ICOP UI Healthcare People, 2018). the department reviews the services offered by the doctors and other clinicians at the hospitals and looks at the hospital's coding and billing. The JOC ensuring that correct coding and billing is issued to the insurance providers for the reimbursements affect the reimbursements of the healthcare organization by ensuring that all the claims the hospitals make to the insurance companies are paid. As a result, the hospital will be reimbursed for all the services offered, meaning that no claims will be rejected. REIMBURSEMENT AND THE REVENUE CYCLE 7 References Abimbola, S., Baatiema, L., & Bigdeli, M. (2019). The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health policy and planning, 34(8), 605-617. Lin, J. C., Kavousi, Y., Sullivan, B., & Stevens, C. (2020). Analysis of outpatient telemedicine reimbursement in an integrated healthcare system. Annals of vascular surgery, 65, 100106. NueMD. (2018). Revenue cycle management 101. Retrieved May 19, 2021, from https://nuemd.com/revenue-cycle-management/rcm-101 RevCycleIntelligence. (2019). What is healthcare revenue cycle management? Retrieved May 19, 2021, from https://revcycleintelligence.com/features/what-is-healthcare-revenuecycle-management Schneider, P. J. (2020). Final Regulations Could Expand the Use of Health Reimbursement Arrangements. Journal of Financial Service Professionals, 74(4). The ICOP UI Healthcare People. (2018). Documentation, coding, and billing department functions. Retrieved May 19, 2021, from https://medcom.uiowa.edu/theloop/announcements/quest-newsletter-documentationcoding-and-billing-department-functions van Gelderen, S. C., Zegers, M., Boeijen, W., Westert, G. P., Robben, P. B., & Wollersheim, H. C. (2017). Evaluation of the organization and effectiveness of internal audits to govern patient safety in hospitals: a mixed-methods study. BMJ Open, 7(7), e015506.
 

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