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 two 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 Three and Five.
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 healthcare 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. 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:
Reimbursement and the Revenue Cycle
Describe what reimbursement means to a healthcare organization. What would happen if services were provided to patients but no payments were received for those services?
- Illustrate the flow of the patient through the cycle from the initial point of contact through the care and ending at the point where the payment is collected
Departmental Impact on Reimbursement
- Many different departments utilize reimbursement data in a healthcare organization. It is crucial the healthcare organization monitors this data. What impact could the healthcare organization face if this data were not monitored? Describe why collecting data is required for pay-for performance incentives.
- Describe the activities within each department in a healthcare organization for how they may impact reimbursement. What specific data would you review in the reimbursement area to know whether changes were necessary?
- Identify the responsible department for ensuring compliance with billing and coding policies. How does this affect the department’s impact on reimbursement in a healthcare organization?
Billing and Reimbursement
- 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?
- 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.
- Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
- 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.
Expert Solution Preview
Reimbursement and the Revenue Cycle:
Reimbursement is a critical aspect for healthcare organizations as it represents the financial compensation received for the services provided to patients. Without reimbursement, healthcare organizations would face significant financial difficulties, as they would not receive payment for the services rendered. This would impact their ability to cover operational costs, invest in new technologies, and provide quality care to patients.
The flow of the patient through the revenue cycle starts from the initial point of contact, where the patient seeks healthcare services. This can be through various channels such as outpatient clinics, emergency departments, or primary care physicians. The patient is then registered, and the necessary demographic and insurance information is collected. The patient’s insurance eligibility is verified, and the patient is triaged or directed to the appropriate department for further evaluation and treatment.
During the course of the patient’s care, various services such as laboratory tests, imaging studies, consultations, and procedures may be performed. Each of these services generates a charge, which is then coded and billed to the patient’s insurance provider. The insurance provider reviews the claim for medical necessity, accuracy, and compliance with their policies. Once the claim is approved, the insurance provider reimburses the healthcare organization for the services provided. The healthcare organization then follows up on any denials or unpaid claims, working towards collecting the payment for services rendered.
Departmental Impact on Reimbursement:
Monitoring reimbursement data is crucial for healthcare organizations as it provides valuable insights into the financial performance and viability of the organization. If reimbursement data is not monitored, the healthcare organization may face several challenges. Firstly, there could be a delay or non-payment for services rendered, which would impact the organization’s cash flow. Secondly, inaccurate or incomplete reimbursement data can lead to underpayment, resulting in a loss of revenue for the organization.
Collecting data is required for pay-for-performance incentives as it helps in measuring and assessing the quality of care provided. By collecting data on key performance indicators, such as patient satisfaction, clinical outcomes, and adherence to best practices, healthcare organizations can demonstrate their commitment to delivering high-quality care. This data is used to determine the reimbursement rates and incentives provided by payers based on the organization’s performance.
Each department within a healthcare organization plays a crucial role in impacting reimbursement. For example, the revenue cycle department ensures accurate coding and billing of services, which directly impacts the reimbursement received. The clinical documentation department ensures that the documentation accurately reflects the services provided, supporting the coding and billing process. The compliance department ensures adherence to billing and coding policies, minimizing the risk of fraudulent activities and potential penalties.
Billing and Reimbursement:
Third-party policies play a significant role in developing billing guidelines for patient financial services (PFS) personnel and administration. PFS personnel and administration need to understand and comply with these policies to determine the payer mix for maximum reimbursement. Third-party policies define the reimbursement rates and guidelines for various services, the types of services covered, and the documentation requirements. By adhering to these policies, healthcare organizations can optimize their revenue streams and maximize reimbursement.
Key areas of review for timeliness and maximization of reimbursement from third-party payers include accurate and timely submission of claims, proper coding of services, and adherence to documentation guidelines. Timely claim submission ensures that the organization receives payment within a reasonable timeframe. Accurate coding and documentation support the medical necessity of the services provided, reducing the risk of denials and underpayment. By prioritizing these areas, healthcare organizations can streamline their billing processes and improve revenue cycle efficiency.
The structure of the follow-up staff should prioritize effectiveness in ensuring timely reimbursement. This can be achieved by assigning dedicated staff members responsible for following up on unpaid claims, denials, and underpayment issues. These staff members should have a strong understanding of the billing and reimbursement processes, as well as the necessary communication and negotiation skills to resolve payment issues with third-party payers. Regular communication and collaboration between the follow-up staff and other departments involved in the revenue cycle are essential to ensure a coordinated approach towards reimbursement.
A plan for periodic review of procedures to ensure compliance should be put in place. This plan should include steps such as regular audits of coding and billing practices, documentation reviews, and training sessions for staff members involved in the revenue cycle. The feasibility of enacting this plan within the organization can be ensured by allocating sufficient resources, including personnel, time, and technology, to support the review process. Additionally, establishing clear goals, timelines, and accountability measures can help track the progress and effectiveness of the plan.
