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:
• 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.
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 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-forperformance 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 department’s 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.
Critical Elements Exemplary Proficient Needs Improvement Not Evident Value Reimbursement and the Revenue Cycle: Reimbursement Meets “Proficient” 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 “Proficient” 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 “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 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 “Proficient” 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 “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%)
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: ThirdParty Policies
Meets “Proficient” 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 “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 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 “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%)
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 “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%)
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 “Proficient” 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 “Proficient” 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 “Proficient” 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 “Proficient” 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%
