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.
