Third party policies and billing guidelines

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.

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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

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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