Healthcare Reimbursement

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.Specifically, the following critical elements must be addressed:
I. Reimbursement and the Revenue Cycle
A. Describe what reimbursement means to a healthcare organization. What would happen if services were provided to patients but no payments were
received for these services?
B. 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. Also identify the departments in order of importance to the revenue cycle.
II. Departmental Impact on Reimbursement
A. 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-forperformance incentives.
B. Describe the activities within each department for how they may impact reimbursement. What specific data would you review in the reimbursement
area to know whether changes were necessary?
C. 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?
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.
C. Evaluate strategies to ensure stakeholders involved in the reimbursement process adhere to ethical standards