Healthcare Reimbursement
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.