Overview
In this module, we introduce the student to the revenue cycle and the different reimbursement methodologies for different healthcare settings.
MODULE INTRODUCTION
Payment for healthcare services is complex and can be difficult to grasp for HIM students. This chapter discusses healthcare insurance, revenue cycle management, reimbursement systems (including private and government plans), managed care, healthcare reimbursement methodologies, and utilization and case management.
Assignment Checklist: (ALL SHOULD BE COMPLETED)
Discussion 13.1: Healthcare Reimbursement Methodologies [4a, 4b, 4c, 4d, 4e, 4g]
Lab Assignment 15.1: Charge Description Master (CDM) [4a, 4b, 4c, 4d, 4e, 4g]
SPC Real World Case 15.1: Community Health Clinic [4a, 4b, 4c, 4d, 4e, 4g]
SPC Real World Case 15.2: Sitlan Community Hospital [4a, 4b, 4c, 4d, 4e, 4g]
Discussion 13.1: Healthcare Reimbursement MethodologiesDiscussion TopicHealthcare Reimbursement Methodologies15 POINTSIn this discussion, briefly describe the following items in your initial Discussion Post:
The reimbursement process.
Common forms used in the billing process.
The support practices utilized for healthcare reimbursement.
- For this discussion, read Chapter 15 and research the internet to gather information. Guidelines
Please make sure your discussion posts include all of the items below:
The reimbursement process.
Common forms used in the billing process.
- The support practices utilized for healthcare reimbursement.
Note: your initial summary post should be one or two paragraphs in length (a paragraph is at least 3 sentences in length).
Reply to at least one classmates’ posts with a substantial thought.
- You must post first before you will be able to view those of your classmates.
View the Discussion Rubric for grading criteria.
- Lab Assignment 15.115 POINTS
Charge Description Master (CDM)
The core of the healthcare revenue cycle is the chargemaster. The chargemaster is a comprehensible list of all billable items that can be billed to either a patient or a patient’s medical insurance company. When a patient receives services, a coder audits the health record for supporting documentation, assigns the appropriate code and the claim is submitted to the patient or the patient’s insurance company for payment.
For this assignment, you will review chapter 15 in your textbook and then answer the following questions in the Quiz Tool, using complete sentences and focusing on relevant details.
What is a chargemaster?
- What codes are utilized in the charge capture process?
Name the 3 codes utilized in the charge capture process.
What is a fee-schedule?
How do all of the above components support the reimbursement process?
Guidelines
Before you submit your written responses:
Ensure all of the Lab Assignment 15.1 questions are answered thoroughly.
View the Lab Assignment Rubric (15 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
Please Note: Each question is worth 3 points for a total of 15 points.
- Lab Assignment 15.115 POINTS
- Charge Description Master (CDM)
The core of the healthcare revenue cycle is the chargemaster. The chargemaster is a comprehensible list of all billable items that can be billed to either a patient or a patient’s medical insurance company. When a patient receives services, a coder audits the health record for supporting documentation, assigns the appropriate code and the claim is submitted to the patient or the patient’s insurance company for payment. - For this assignment, you will review chapter 15 in your textbook and then answer the following questions in the Quiz Tool, using complete sentences and focusing on relevant details.
- What is a chargemaster?
What codes are utilized in the charge capture process?
Name the 3 codes utilized in the charge capture process.
What is a fee-schedule?
How do all of the above components support the reimbursement process?
Guidelines
Before you submit your written responses:
Ensure all of the Lab Assignment 15.1 questions are answered thoroughly.
View the Lab Assignment Rubric (15 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
- Please Note: Each question is worth 3 points for a total of 15 points.
- Real World Case 15.120 POINTS
- For this activity, you will review the Real World Case 15.1. You will conduct an analysis of the situation and summarize how you would have addressed the issues.
A student on an outside clinical rotation from a local HIM program has been tasked with mapping the revenue cycle for an outpatient visit at the Community Health Clinic. She started with the Registration Department, next was Coding, and ending with the Billing Department.
Analyze Real World Case 15.1:
A student from an accredited HIM program was given the project of mapping the revenue cycle for a simple outpatient visit to the Community Health Clinic where she was doing her internship. She started with the registration department and determined the clerks were not obtaining copies of insurance cards but were taking the information orally from patients. She then determined that the coding department was using CPT (current procedural terminology) codes that were from the prior year. Finally, in reviewing the remittance advice notice from the insurance carriers she noticed that the patients were never balance billed for the claim amount for which they were responsible.
For this assignment, you will identify the deficiencies the student found within each of the 3 departments she was asked to review, offer suggestions on how to improve the current processes, and outline the changes each department involved must make in order to increase the clinics billing revenue.
- You will then answer the following questions in the Quiz Tool, using complete sentences and focusing on relevant details.
What are some of the problems with the revenue cycle for Community Health Clinic?
- Outline suggestions for changes to the process for this clinic to improve the efficiency of the revenue cycle management.
Which departments are responsible for the revenue cycle problems at Community Health Clinic?
- Guidelines
Before you submit your Real World Case Study written responses:
Ensure all of the Real World Case Study 15.1 questions are answered thoroughly.
View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
Please Note: Each question is worth 6.66 points for a total of 20 points.
Real World Case 15.120 POINTS
For this activity, you will review the Real World Case 15.1 on page 443 of your textbook. You will conduct an analysis of the situation and summarize how you would have addressed the issues.
A student on an outside clinical rotation from a local HIM program has been tasked with mapping the revenue cycle for an outpatient visit at the Community Health Clinic. She started with the Registration Department, next was Coding, and ending with the Billing Department.
Analyze Real World Case 15.1. For this assignment, you will identify the deficiencies the student found within each of the 3 departments she was asked to review, offer suggestions on how to improve the current processes, and outline the changes each department involved must make in order to increase the clinics billing revenue.
You will then answer the following questions in the Quiz Tool, using complete sentences and focusing on relevant details.
What are some of the problems with the revenue cycle for Community Health Clinic?
Outline suggestions for changes to the process for this clinic to improve the efficiency of the revenue cycle management.
Which departments are responsible for the revenue cycle problems at Community Health Clinic?
Guidelines
Before you submit your Real World Case Study written responses:
Ensure all of the Real World Case Study 15.1 questions are answered thoroughly.
View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
Please Note: Each question is worth 6.66 points for a total of 20 points.
- Real World Case 15.220 POINTS
- For this activity, you will review the Real World Case 15.2. You will conduct an analysis of the situation and summarize how you would have addressed the issues.
Hospital-acquired infections can be caused by viral, bacterial, and fungal pathogens. Risk factors for healthcare-associated infections can be from injections, catheters, central lines, surgeries, and passing from healthcare workers to patients or patients to healthcare workers due to poor hygiene.
- Analyze Real World Case 15.2.
- For this assignment, you will conduct an analysis of Emily Kelly, an appendectomy surgical patient who developed a post-op infection in her surgical site. The billing department noticed the reimbursement rate for Emily’s surgery was lower than expected. Your analysis should include the reason for the reimbursement, why the infection rates for Sitlan Community Hospital are so high, and what can patients do in regards to seeking care in other healthcare facilities.
You will then answer the following questions in the Quiz Tool, using complete sentences and focusing on relevant details.
Why would the reimbursement rate decrease for this hospital?
What should the hospital do to determine why the infection rates are high?
What can patients do if they have choices of where to go for their care?
Guidelines
Before you submit your Real World Case Study written responses:
Ensure all of the Real World Case Study 15.2 questions are answered thoroughly.
View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
Please Note: Each question is worth 6.66 points for a total of 20 points.
Real World Case 15.220 POINTS
- For this activity, you will review the Real World Case 15.2 on page 444 of your textbook. You will conduct an analysis of the situation and summarize how you would have addressed the issues.
Hospital-acquired infections can be caused by viral, bacterial, and fungal pathogens. Risk factors for healthcare-associated infections can be from injections, catheters, central lines, surgeries, and passing from healthcare workers to patients or patients to healthcare workers due to poor hygiene.
Analyze Real World Case 15.2. For this assignment, you will conduct an analysis of Emily Kelly, an appendectomy surgical patient who developed a post-op infection in her surgical site. The billing department noticed the reimbursement rate for Emily’s surgery was lower than expected. Your analysis should include the reason for the reimbursement, why the infection rates for Sitlan Community Hospital are so high, and what can patients do in regards to seeking care in other healthcare facilities.
- You will then answer the following questions in the Quiz Tool, using complete sentences and focusing on relevant details.
Why would the reimbursement rate decrease for this hospital?
What should the hospital do to determine why the infection rates are high?
What can patients do if they have choices of where to go for their care?
Expert Solution Preview
Introduction:
As a medical professor, I am responsible for creating college assignments and evaluating student performance in medical college. In this module, we will be discussing the revenue cycle and the different reimbursement methodologies for different healthcare settings.
Discussion 13.1: Healthcare Reimbursement Methodologies
The reimbursement process involves the payment of funds to healthcare organizations for services provided to patients. Common forms used in the billing process include the UB-04 and the CMS-1500. The support practices utilized for healthcare reimbursement include coding and documentation standards, as well as guidelines established by private and government insurance plans. These practices ensure that claims are submitted properly and that organizations receive full reimbursement for services provided.
Lab Assignment 15.1: Charge Description Master (CDM)
A chargemaster is a comprehensive list of all billable items that can be billed to either a patient or a patient’s medical insurance company. The codes utilized in the charge capture process include CPT, HCPCS, and ICD-10-CM. A fee-schedule is a listing of payment rates established by a healthcare organization for various services and procedures. All of these components support the reimbursement process by ensuring accurate billing and coding practices, which in turn leads to full reimbursement for services provided.
Real World Case 15.1
The problems with the revenue cycle for Community Health Clinic include the lack of insurance card verification in the registration department, outdated CPT codes in the coding department, and failure to balance bill patients for the claim amount for which they are responsible in the billing department. Suggestions for changes to improve revenue cycle management include implementing a policy for insurance card verification, regularly updating CPT codes, and ensuring that patients are balance billed for their portion of the claim. Each department involved is responsible for addressing the deficiencies found in their respective areas.
Real World Case 15.2
Healthcare-associated infections can be prevented by implementing strict hygiene protocols, utilizing patient isolation procedures when necessary, and carefully monitoring patients for signs of infection. Risk factors can be reduced through proper insertion and maintenance of catheters and other medical devices, as well as appropriate hand hygiene practices by healthcare workers. Healthcare organizations have a responsibility to implement these preventive measures in order to minimize the risk of hospital-acquired infections.
#Chapter #Revenue #Management #Reimbursement
