Project Milestone Two: Draft of Billing, Marketing, and Reimbursement
HCM 345 Milestone Two Guidelines and Rubric
Overview: 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.
Milestone Two provides you an opportunity to engage with real-world data and tools that you would encounter in an actual professional environment. Specifically, you will begin thinking about reimbursement in terms of billing and marketing. Reimbursement is a complex process with several stakeholders; this milestone allows you to begin thinking about the key players, including third-party billing, data collection, staff management, and ensuring compliance. Marketing and communication also plays a vital role in reimbursement; this milestone offers a chance to begin analyzing effective strategies and their impact.
Prompt: Submit your draft of Sections III and IV of the final project. Specifically, the following critical elements must be addressed:
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.
Rubric
Guidelines for Submission: Your draft must be submitted as a three- to five-page Microsoft Word document with double spacing, 12-point Times New Roman font, one-inch margins, and at least three sources, which should be cited in APA format.
Critical Elements |
Proficient (100%) |
Needs Improvement (75%) |
Not Evident (0%) |
Value |
Billing and Reimbursement: Data |
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 |
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 |
Does not analyze the collection of data by patient access personnel |
10 |
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 |
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 |
Does not analyze how third-party policies would be used |
10 |
Billing and Reimbursement: Key Areas of Review |
Organizes and explains the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers |
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 |
Does not organize and explain the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers |
10 |
Billing and Reimbursement: Structure |
Describes a way to structure follow-up staff in terms of effectiveness and explains rationale for effectiveness |
Describes a way to structure follow-up staff in terms of effectiveness but does not explain rationale for effectiveness |
Does not describe a way to structure follow- up staff in terms of effectiveness |
10 |
Billing and Reimbursement: Plan |
Develops a plan for periodic review of procedures to ensure compliance, including explicit steps and the feasibility of enacting the plan |
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 |
Does not develop a plan for periodic review of procedures to ensure compliance |
10 |
Marketing and Reimbursement: Strategies |
Analyzes the strategies used to negotiate new managed care contracts, supporting analysis with research |
Analyzes the strategies used to negotiate new managed care contracts but does not support analysis with research |
Does not analyze the strategies used to negotiate new managed care contracts |
10 |
Critical Elements |
Proficient (100%) |
Needs Improvement (75%) |
Not Evident (0%) |
Value |
Marketing and Reimbursement: Communicate |
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 |
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 |
Does not communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts |
10 |
Marketing and Reimbursement: Contracts |
Explains how new managed care contracts impact reimbursement for the healthcare organization, including support for explanation with concrete evidence or research |
Explains how new managed care contracts impact reimbursement for the healthcare organization but does not include support for explanation with concrete evidence or research |
Does not explain how new managed care contracts impact reimbursement for the healthcare organization |
10 |
Marketing and Reimbursement: Compliance |
Comprehensively discusses the resources needed to ensure billing and coding compliance with regulations and ethical standards |
Discusses the resources needed to ensure billing and coding compliance with regulations and ethical standards, but discussion is not comprehensive |
Does not discuss the resources needed to ensure billing and coding compliance |
10 |
Articulation of Response |
Submission has no major errors related to citations, grammar, spelling, syntax, or organization |
Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas |
Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas |
10 |
Total |
100% |
Project Milestone Two
Your Name
Subject and Section
Professor’s Name
June 7, 2021
Billing and Reimbursement
* Analyze data collection by patient access personnel (nurses, coders, etc.) and its importance to the billing and collection process. Be sure to address the importance of exceptional customer service.
Both billing and coding systems are crucial for the healthcare system. If these processes are not done correctly, it could lead to inaccuracies and loss on the healthcare provider, which might endanger healthcare professionals in the long run. Accordingly, in this process, several staffs are crucial for ensuring a smooth and accurate operation. On the one hand, the nurses and staff have the responsibility to determine the patient's health and other related information. On the other hand, it is the coders who are tasked with encoding and verifying the insurance claims' accuracy from insurance providers.
Finally, exceptional customer service is also important so that 'trust is built between all of the stakeholders. It would help in improving the overall process of payment and insurance claims CITATION Kin211 \l 1033 (Kinger, 2021).
* 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.
The department of Patient Financial Services (PFS) is one of the departments in the hospital that is mainly designed to help its patients facilitate their payments and insurance claims, among others. It includes giving advice and telling the patients about the extent of their claims.
Accordingly, third-party policies that guide the PFS department are also important to allow the provider to claim maximum reimbursement. For example, these third-party policies mandate that the whole process be efficient and effective through necessary training and guidance to the personnel. Additionally, these policies also demand that the supervisor be proactive in providing suggestions and implementations that would focus on maximum reimbursements.
* Organize the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain your rationale for the order.
The five key areas must be focused on to ensure punctual a...