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 three 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
One, Three, and Five.
In this assignment, you will demonstrate your mastery of the
following course outcomes:
? Analyze the impacts of various healthcare departments and
their interrelationships on the revenue cycle
? Compare third-party payer policies through analysis of reimbursement
guidelines for achieving timely and maximum reimbursements ? Analyze organizational strategies for
negotiating healthcare contracts with managed care organizations ? Critique legal and ethical standards and
policies in healthcare coding and billing for ensuring compliance with rules
and regulations ? 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.
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. Beckerâs 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 physicianâagain, 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 this
specific healthcare organization. What would happen if services were provided
to patients but no payments were received for these services? What specific
data would you review in the reimbursement area to know whether changes were
necessary? B. Illustrate the revenue cycle using a flowchart tool. Take the
patient through the cycle from the initial point of contact through the care
and ending at the point where the payment is collected.
C. Prioritize the
departments at this specific healthcare organization in order of their
importance to the revenue cycle. Support your ordering of the departments with
evidence.
II. Departmental Impact on Reimbursement A. Describe the
impact of the departments at this 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-for- performance incentives be measured? B.
Assess the activities within each department at this healthcare organization
for how they may impact reimbursement. C. Identify the responsible department
for ensuring compliance with billing and coding policies. How does this affect
the departmentâs impact on reimbursement at this healthcare organization?
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 One, you will submit a draft of Section I of the final project
(Reimbursement and the Revenue Cycle). This milestone will be graded with the
Milestone One Rubric. Milestone Two:
Draft of Departmental Impact on Reimbursement In Module Three, you will submit
a draft of Section II of the final project (Departmental Impact on
Reimbursement). This milestone will be graded with the Milestone Two
Rubric.
Milestone Three: 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 Three 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.
Deliverables
Milestone Deliverable Module Due Grading
One Draft of Reimbursement and the Revenue Cycle
One Graded separately; Milestone One Rubric
Two Draft of Departmental Impact on Reimbursement
Three Graded separately; Milestone Two Rubric
Three Draft of Billing, Marketing, and Reimbursement
Five Graded separately; Milestone Three Rubric
Final Project
Submission: White Paper 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 one-inch margins. Citations should be
formatted according to APA style.
Instructor Feedback: This activity uses an integrated rubric
in Blackboard. Students can view instructor feedback in the Grade Center. For
more information, review these instructions.
Critical Elements Exemplary Proficient Needs Improvement Not Evident Value Reimbursement and the Revenue Cycle:
Reimbursement Meets âProficientâ criteria and includes any unique attributes of
this specific organization (100%) Comprehensively describes what reimbursement
means to this specific healthcare organization (85%) Describes what
reimbursement means to a healthcare organization, but description is not
comprehensive or is not specific (55%) Does not describe what reimbursement
means to a specific healthcare organization (0%) 6.33 Reimbursement and the
Revenue Cycle: Revenue Accurately
illustrates the revenue cycle using a flowchart (100%) Illustrates the revenue
cycle using a flowchart, but illustration is inaccurate or incomplete (55%)
Does not illustrate the revenue cycle using a flowchart (0%) 6.33 Reimbursement
and the Revenue Cycle: Prioritize Meets âProficientâ criteria, and
prioritization demonstrates nuanced insight into departmental influence on the
revenue cycle (100%) Prioritizes the departments at this specific healthcare
organization in order of importance to the revenue cycle, supporting ordering
of departments with evidence (85%) Prioritizes the departments at a healthcare
organization in order of importance to the revenue cycle but is not specific to
this healthcare organization or does not include support for ordering (55%)
Does not prioritize the departments at a healthcare organization in order of
importance to the revenue cycle (0%) 6.33 Departmental Impact on Reimbursement:
Departments Meets âProficientâ 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 at this healthcare organization that also influence
reimbursement (85%) Describes the impact of the departments that influence
reimbursement, but description is not comprehensive or is not specific to this
healthcare organization or to departments that utilize reimbursement data (55%)
Does not describe the impact of the departments at a healthcare organization
that influence reimbursement (0%) 6.33 Departmental Impact on Reimbursement:
Activities Meets âProficientâ criteria, and assessment demonstrates keen insight
into the relationship between departmental activities and healthcare
reimbursement (100%) Assesses the activities within each department at this
healthcare organization for how they may impact reimbursement (85%) Assesses
the activities within each department at this healthcare organization but does
not explicitly link these activities to reimbursement, or assessment is not
specific (55%) Does not assess the activities within each department at a
healthcare organization for how they may impact reimbursement (0%) 6.33
Departmental Impact on Reimbursement: Responsible Department
Correctly identifies
the department responsible for ensuring compliance of billing and coding
policies and its impact on reimbursement at this healthcare organization (100%)
Identifies the department responsible for ensuring
compliance of billing and coding policies and its impact on reimbursement at
this healthcare organization, but identification is incorrect (55%)
Does not identify the department responsible for ensuring compliance
of billing and coding policies (0%)
6.33
Billing and Reimbursement: Data
Meets âProficientâ criteria, and analysis demonstrates a
nuanced insight into the relationship between patient access personnelâs
collection of data and the billing and collection process (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%)
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%)
Does not analyze the collection of data by patient access
personnel (0%)
6.33
Billing and Reimbursement: Third- Party Policies
Meets âProficientâ criteria, and analysis demonstrates a
keen insight into the relationships between third-party policies, billing
guidelines, and payer mix (100%)
Analyzes how third-party policies would be used when
developing billing guidelines for PFS personnel and administration when
determining the payer mix for maximum reimbursement (85%)
Analyzes how third-party policies would be used but does not
apply analysis toward the development of billing guidelines for PFS personnel
and administration or toward the determination of the payer mix for maximum
reimbursement (55%)
Does not analyze how third-party policies would be used (0%)
6.33
Billing and Reimbursement: Key Areas of Review
Meets âProficientâ criteria, and explanation of key areas of
review demonstrates a nuanced insight into reimbursement from third- party
payers (100%)
Organizes and explains the key areas of review in order of
importance for timeliness and maximization of reimbursement from third-party
payers (85%)
Organizes and explains the key areas of review in order of
importance for timeliness and maximization of reimbursement from third-party
payers, but explanation is cursory or illogical (55%)
Does not organize and explain the key areas of review in
order of importance for timeliness and maximization of reimbursement from
third-party payers (0%)
6.33
Billing and Reimbursement: Structure
Meets âProficientâ criteria and demonstrates creativity in
the structure identified (100%)
Describes a way to structure follow-up staff in terms of
effectiveness and explains rationale for effectiveness (85%)
Describes a way to structure follow-up staff in terms of
effectiveness but does not explain rationale for effectiveness (55%)
Does not describe a way to structure follow-up staff in
terms of effectiveness (0%)
6.33
Billing and Reimbursement: Plan
Meets âProficientâ criteria and demonstrates ingenuity in
the review process (100%)
Develops a plan for periodic review of procedures to ensure
compliance, including explicit steps and the feasibility of enacting the plan
(85%)
Develops a plan for periodic review of procedures to ensure
compliance but does not include explicit steps or does not include the
feasibility of enacting the plan (55%)
Does not develop a plan for periodic review of procedures to
ensure compliance (0%)
6.33
Marketing and Reimbursement: Strategies
Meets âProficientâ criteria, and research includes specific
examples applicable to negotiation strategies (100%)
Analyzes the strategies used to negotiate new managed care
contracts, supporting analysis with research (85%)
Analyzes the strategies used to negotiate new managed care
contracts but does not support analysis with research (55%)
Does not analyze the strategies used to negotiate new
managed care contracts (0%)
6.33
Marketing and Reimbursement: Communicate
Meets âProficientâ criteria and communicates this in a
manner that would be motivational for the individual (100%)
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%)
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%)
Does not communicate the important role that each individual
within this healthcare organization plays with regard to managed care contracts
(0%)
6.33
Marketing and Reimbursement: Contracts
Meets âProficientâ criteria and includes enough information
to make informed decisions on accepting the contract (100%)
Explains how new managed care contracts impact reimbursement
for the healthcare organization, including support for explanation with
concrete evidence or research (85%)
Explains how new managed care contracts impact reimbursement
for the healthcare organization but does not include support for explanation
with concrete evidence or research (55%)
Does not explain how new managed care contracts impact
reimbursement for the healthcare organization (0%)
6.33
Marketing and Reimbursement: Compliance
Meets âProficientâ criteria and includes details such as how
often the resources should be updated to stay current with regulations (100%)
Comprehensively discusses the resources needed to ensure
billing and coding compliance with regulations and ethical standards (85%)
Discusses the resources needed to ensure billing and coding
compliance with regulations and ethical standards, but discussion is not
comprehensive (55%)
Does not discuss the resources needed to ensure billing and
coding compliance (0%)
6.33
Articulation of Response
Submission is free of errors related to citations, grammar,
spelling, syntax, and organization and is presented in a professional and easy
to read format (100%)
Submission has no major errors related to citations,
grammar, spelling, syntax, or organization (85%)
Submission has major errors related to citations, grammar,
spelling, syntax, or organization that negatively impact readability and
articulation of main ideas (55%)
Submission has critical errors related to citations,
grammar, spelling, syntax, or organization that prevent understanding of ideas
(0%)
5.05
Earned Total 100%
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