Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization

Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization




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.

In Milestone Two, 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 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? b. 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. c. Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective? d. 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. Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete evidence or research. b. 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. c. Evaluate strategies to ensure stakeholders involved the reimbursement process adhere to ethical standards.

1 Milestone Project Dania A 3-2 Final Project Milestone One: Draft of Departmental Impact on Reimbursement January 22, 2023 2 Section 1 a. Meaning of reimbursement to a healthcare organization Reimbursement to a healthcare organization generally means the form of payment that such healthcare organizations typically receive for issuing medical services to patients. In most cases, such costs are generally settled by the patient’s health insurer or the government. Employers primarily fund healthcare reimbursement plans to cover their employees’ medical expenses (Chalasani & Koritala, 2019). Therefore, it is crucial to understand that healthcare reimbursement cannot be categorized as part of health insurance but rather as providing employees with allowances that can be used to cover their medical bills. If the patients receive medical care, but the payments of the services received are not paid for, then the patient will be liable for paying the bills. If the patient cannot pay the medical bills, the healthcare organization has the right to sue the patient personally. b. The flow of the patient The flow of the patient through the cycle, starting from when the contact towards the end when payments for medical services are received, is made up of seven different steps. The following are the key steps: Pre-registration- The first step is normally the pre-registration which the clinic care unit department performs within the healthcare organization. This step plays a significant role in gathering some key information about the patient while still on the phone, including their respective demographic information. The step is critical in determining any financial expectations by the healthcare organization. 3 Registration- Registration plays a significant role in determining the accuracy of the information provided by the patients. The healthcare organization is responsible for securing the data gathered during the registration step. Charge capture- The HMIS department typically performs the charge capture step within a healthcare organization. The front desk personnel within the organization is normally responsible for inputting all necessary information about the patients and how much they will be charged for the services. Claim submission- The accounting department normally performs this step within the healthcare organization. The department is responsible for sending information to the insurance company for each of the respective patients concerning the charges for their services. If different services were issued to the patient, those services should be submitted separately. Remittance processing- This step includes the insurance carrier sending back information to the healthcare organizations specifying the type of charges they have paid for. The steps are also associated with determining any possible allowable. Negotiations between the healthcare organization and the insurance carrier normally occur during this step, including the charges for each service offered. Insurance follow-up- This step includes the accounts department of the healthcare organization checking the accounts receivables to determine the amount of money paid by the insurance carrier. The primary aim of this step is to determine the type of services which still need to be paid for by the insurance carrier. 4 Patient collections- The finance department normally performs this step within the healthcare organization. It is important to understand that the providers normally collect money from the patients when they are still within the organization. Section 2 a. Monitoring crucial data by healthcare organization All departments within a healthcare organization must ensure that the payments received reflect the type of services the patients receive. Therefore, the data should be accurately monitored. Failure to monitor crucial data by healthcare organizations consequently reduces the amount of money received from insurance carriers (Das & Gonzalez, 2020). Additionally, failure to monitor the data can also result in various errors during financial computations. Failure to collect the correct amount of money will then mean that the services offered by the healthcare organization will drastically reduce since they can no longer fund the services. It is always recommendable to collect data for pay-for-performance incentives. That is mainly because they can serve as an approach for assessing the healthcare organization’s goals. All departments within a healthcare organization have their respective goals, and measuring the pay-for-performance incentives can assist in determining how such goals can be achieved. The data collected will be used to compare the performance of the veracious departments before the pay-for-performance incentives and after they have been introduced. b. Activities within each department One of the most critical departments within a healthcare organization that impacts reimbursement is the clinical service department. The activities performed by this department include recording all necessary information about the patients and the type of services received 5 from the healthcare organization. Other information recorded by the department about the patients includes their demographic information (Salvatore et al., 2021). Therefore, the accuracy of the information collected by the department is paramount since other parties will use the same information. A key data that should be reviewed during the reimbursement to determine whether there are any changes needed is the chargemaster which plays a significant role in collecting and recording any necessary information concerning the transactions made by the patient. Therefore, the accuracy of the chargemaster is critical in ensuring that the accuracy of all other information is maintained. If the accounting department delays developing a patient’s chart, including their financial transactions, that will consequently result in delays in the reimbursement. c. Departments for billing and coding policies A critical department responsible for billing and coding policies is the administration department. The department checks whether the regulation standards have been met during the reimbursement process. The department impacts reimbursements within the organization by maintaining the effectiveness of the process. That is primarily because of the effective adherence to the set systems and policies. 6 References Chalasani, S., & Koritala, S. (2019). An integrated case to teach healthcare reimbursement. Business Education Innovation Journal, 11(1), 230-240. Das, L. T., & Gonzalez, C. J. (2020). Preparing telemedicine for the frontlines of healthcare equity. Journal of General Internal Medicine, 35(8), 2443-2444. Salvatore, F. P., Fanelli, S., Donelli, C. C., & Milone, M. (2021). Value-based healthcare principles in healthcare organizations. International Journal of Organizational Analysis.