HCM 345 Final Project Guidelines and Rubric
Overview
The final project for this course is the creation of a white
paper.
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 three 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
One, Three, and Five.
In this assignment, you will demonstrate your mastery of the
following course outcomes:
? Analyze the impacts of various healthcare departments and
their interrelationships on the revenue cycle
? Compare third-party payer policies through analysis of
reimbursement guidelines for achieving timely and maximum reimbursements
? Analyze organizational strategies for negotiating
healthcare contracts with managed care organizations
? Critique legal and ethical standards and policies in
healthcare coding and billing for ensuring compliance with rules and
regulations
? Evaluate the use of reimbursement data for its purpose in
case and utilization management and healthcare quality improvement as well as
its impact on
pay for performance incentives
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 hospital
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. There
are several ways to accomplish this. Choose one of the
following:
? If you have been a patient in a hospital or if you know
someone who has, you can use that experience as the basis for your responses.
? 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:
I. Reimbursement and the Revenue Cycle
A. Describe what reimbursement means to this specific
healthcare organization. What would happen if services were provided to
patients but no
payments were received for these services? What specific
data would you review in the reimbursement area to know whether changes were
necessary?
B. Illustrate the revenue cycle using a flowchart tool. Take
the patient through the cycle from the initial point of contact through the
care and
ending at the point where the payment is collected.
C. Prioritize the departments at this specific healthcare
organization in order of their importance to the revenue cycle. Support your
ordering of the
departments with evidence.
II. Departmental Impact on Reimbursement
A. Describe the impact of the departments at this healthcare
organization that utilize reimbursement data. What type of audit would be
necessary
to determine whether the reimbursement impact is reached
fully by these departments? How could the impact of these departments on
pay-forperformance
incentives be measured?
B. Assess the activities within each department at this
healthcare organization for how they may impact reimbursement.
C. Identify the responsible department for ensuring
compliance with billing and coding policies. How does this affect the
department’s impact on
reimbursement at this healthcare organization?
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.
Milestones
Milestone One: Draft of Reimbursement and the Revenue Cycle
In Module One, you will submit a draft of Section I of the
final project (Reimbursement and the Revenue Cycle). This milestone will be
graded with the
Milestone One Rubric.
Milestone Two: Draft of Departmental Impact on Reimbursement
In Module Three, you will submit a draft of Section II of
the final project (Departmental Impact on Reimbursement). This milestone will
be graded with the
Milestone Two Rubric.
Milestone Three: Draft of Billing, Marketing, and
Reimbursement
In Module Five, you will submit a draft of Sections III and
IV of the final project (Billing and Reimbursement, and Marketing and
Reimbursement). This milestone
will be graded with the Milestone Three Rubric.
Final Project Submission: White Paper
In Module Seven, you will submit your entire white paper. It
should be a complete, polished artifact containing all of the critical elements
of the final product. It
should reflect the incorporation of feedback gained
throughout the course. This submission will be graded using the Final Project
Rubric.
Deliverables
Milestone Deliverable Module Due Grading
One Draft of Reimbursement and the Revenue
Cycle
One Graded separately; Milestone One Rubric
Two Draft of Departmental Impact on
Reimbursement
Three Graded separately; Milestone Two Rubric
Three Draft of Billing, Marketing, and
Reimbursement
Five Graded separately; Milestone Three Rubric
Final Project Submission: White Paper Seven Graded
separately; Final Project Rubric
Final Project Rubric
Guidelines for Submission: This white paper should include a
table of contents and sections that can be easily separated for each department
area. It should be a
minimum of eight pages (in addition to the title page and
references). The document should use 12-point Times New Roman font, double
spacing, and one-inch
margins. Citations should be formatted according to APA
style.
Instructor Feedback: This activity uses an integrated rubric
in Blackboard. Students can view instructor feedback in the Grade Center. For
more information,
review these instructions.
Critical Elements Exemplary Proficient Needs Improvement Not
Evident Value
Reimbursement and
the Revenue Cycle:
Reimbursement
Meets “Proficient” criteria and
includes any unique attributes of
this specific organization (100%)
Comprehensively describes what
reimbursement means to this
specific healthcare organization
(85%)
Describes what reimbursement
means to a healthcare
organization, but description is
not comprehensive or is not
specific (55%)
Does not describe what
reimbursement means to a
specific healthcare organization
(0%)
6.33
Reimbursement and
the Revenue Cycle:
Revenue
Accurately illustrates the revenue
cycle using a flowchart (100%)
Illustrates the revenue cycle using
a flowchart, but illustration is
inaccurate or incomplete (55%)
Does not illustrate the revenue
cycle using a flowchart (0%)
6.33
Reimbursement and
the Revenue Cycle:
Prioritize
Meets “Proficient” criteria, and
prioritization demonstrates
nuanced insight into
departmental influence on the
revenue cycle (100%)
Prioritizes the departments at this
specific healthcare organization in
order of importance to the
revenue cycle, supporting
ordering of departments with
evidence (85%)
Prioritizes the departments at a
healthcare organization in order
of importance to the revenue
cycle but is not specific to this
healthcare organization or does
not include support for ordering
(55%)
Does not prioritize the
departments at a healthcare
organization in order of
importance to the revenue cycle
(0%)
6.33
Departmental Impact
on Reimbursement:
Departments
Meets “Proficient” criteria and
communicates the impact in a
style that adheres to authentic
formatting for the business of
healthcare (100%)
Comprehensively describes the
impact of the departments that
utilize reimbursement data at this
healthcare organization that also
influence reimbursement (85%)
Describes the impact of the
departments that influence
reimbursement, but description is
not comprehensive or is not
specific to this healthcare
organization or to departments
that utilize reimbursement data
(55%)
Does not describe the impact of
the departments at a healthcare
organization that influence
reimbursement (0%)
6.33
Departmental Impact
on Reimbursement:
Activities
Meets “Proficient” criteria, and
assessment demonstrates keen
insight into the relationship
between departmental activities
and healthcare reimbursement
(100%)
Assesses the activities within each
department at this healthcare
organization for how they may
impact reimbursement (85%)
Assesses the activities within each
department at this healthcare
organization but does not
explicitly link these activities to
reimbursement, or assessment is
not specific (55%)
Does not assess the activities
within each department at a
healthcare organization for how
they may impact reimbursement
(0%)
6.33
Departmental Impact
on Reimbursement:
Responsible
Department
Correctly identifies the
department responsible for
ensuring compliance of billing and
coding policies and its impact on
reimbursement at this healthcare
organization (100%)
Identifies the department
responsible for ensuring
compliance of billing and coding
policies and its impact on
reimbursement at this healthcare
organization, but identification is
incorrect (55%)
Does not identify the department
responsible for ensuring
compliance of billing and coding
policies (0%)
6.33
Billing and
Reimbursement: Data
Meets “Proficient” criteria, and
analysis demonstrates a nuanced
insight into the relationship
between patient access
personnel’s collection of data and
the billing and collection process
(100%)
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 (85%)
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
(55%)
Does not analyze the collection of
data by patient access personnel
(0%)
6.33
Billing and
Reimbursement: ThirdParty
Policies
Meets “Proficient” criteria, and
analysis demonstrates a keen
insight into the relationships
between third-party policies,
billing guidelines, and payer mix
(100%)
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
(85%)
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 (55%)
Does not analyze how third-party
policies would be used (0%)
6.33
Billing and
Reimbursement: Key
Areas of Review
Meets “Proficient” criteria, and
explanation of key areas of review
demonstrates a nuanced insight
into reimbursement from thirdparty
payers (100%)
Organizes and explains the key
areas of review in order of
importance for timeliness and
maximization of reimbursement
from third-party payers (85%)
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
(55%)
Does not organize and explain the
key areas of review in order of
importance for timeliness and
maximization of reimbursement
from third-party payers (0%)
6.33
Billing and
Reimbursement:
Structure
Meets “Proficient” criteria and
demonstrates creativity in the
structure identified (100%)
Describes a way to structure
follow-up staff in terms of
effectiveness and explains
rationale for effectiveness (85%)
Describes a way to structure
follow-up staff in terms of
effectiveness but does not explain
rationale for effectiveness (55%)
Does not describe a way to
structure follow-up staff in terms
of effectiveness (0%)
6.33
Billing and
Reimbursement: Plan
Meets “Proficient” criteria and
demonstrates ingenuity in the
review process (100%)
Develops a plan for periodic
review of procedures to ensure
compliance, including explicit
steps and the feasibility of
enacting the plan (85%)
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
(55%)
Does not develop a plan for
periodic review of procedures to
ensure compliance (0%)
6.33
Marketing and
Reimbursement:
Strategies
Meets “Proficient” criteria, and
research includes specific
examples applicable to
negotiation strategies (100%)
Analyzes the strategies used to
negotiate new managed care
contracts, supporting analysis
with research (85%)
Analyzes the strategies used to
negotiate new managed care
contracts but does not support
analysis with research (55%)
Does not analyze the strategies
used to negotiate new managed
care contracts (0%)
6.33
Marketing and
Reimbursement:
Communicate
Meets “Proficient” criteria and
communicates this in a manner
that would be motivational for
the individual (100%)
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 (85%)
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 (55%)
Does not communicate the
important role that each
individual within this healthcare
organization plays with regard to
managed care contracts (0%)
6.33
Marketing and
Reimbursement:
Contracts
Meets “Proficient” criteria and
includes enough information to
make informed decisions on
accepting the contract (100%)
Explains how new managed care
contracts impact reimbursement
for the healthcare organization,
including support for explanation
with concrete evidence or
research (85%)
Explains how new managed care
contracts impact reimbursement
for the healthcare organization
but does not include support for
explanation with concrete
evidence or research (55%)
Does not explain how new
managed care contracts impact
reimbursement for the healthcare
organization (0%)
6.33
Marketing and
Reimbursement:
Compliance
Meets “Proficient” criteria and
includes details such as how often
the resources should be updated
to stay current with regulations
(100%)
Comprehensively discusses the
resources needed to ensure
billing and coding compliance
with regulations and ethical
standards (85%)
Discusses the resources needed
to ensure billing and coding
compliance with regulations and
ethical standards, but discussion
is not comprehensive (55%)
Does not discuss the resources
needed to ensure billing and
coding compliance (0%)
6.33
Articulation of
Response
Submission is free of errors
related to citations, grammar,
spelling, syntax, and organization
and is presented in a professional
and easy to read format (100%)
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
(85%)
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact readability
and articulation of main ideas
(55%)
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas (0%)
5.05
Earned Total 100%
