Milestone Two

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.

In Milestone Two, 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.

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Specifically, the following critical elements must be addressed:

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 and ethical standards. What would happen if these resources were not obtained? Describe the consequences of noncompliance with regulations and ethical standards. c. Evaluate strategies to ensure stakeholders involved the reimbursement process adhere to ethical standards.

Milestone Project
Dania A
3-2 Final Project Milestone One: Draft of Departmental Impact on Reimbursement
January 22, 2023
Section 1
a. Meaning of reimbursement to a healthcare organization
Reimbursement to a healthcare organization generally means the form of payment that such
healthcare organizations typically receive for issuing medical services to patients. In most cases,
such costs are generally settled by the patient’s health insurer or the government. Employers
primarily fund healthcare reimbursement plans to cover their employees’ medical expenses
(Chalasani & Koritala, 2019). Therefore, it is crucial to understand that healthcare
reimbursement cannot be categorized as part of health insurance but rather as providing
employees with allowances that can be used to cover their medical bills.
If the patients receive medical care, but the payments of the services received are not paid
for, then the patient will be liable for paying the bills. If the patient cannot pay the medical bills,
the healthcare organization has the right to sue the patient personally.
b. The flow of the patient
The flow of the patient through the cycle, starting from when the contact towards the end when
payments for medical services are received, is made up of seven different steps. The following
are the key steps:
Pre-registration- The first step is normally the pre-registration which the clinic care unit
department performs within the healthcare organization. This step plays a significant role in
gathering some key information about the patient while still on the phone, including their
respective demographic information. The step is critical in determining any financial
expectations by the healthcare organization.
Registration- Registration plays a significant role in determining the accuracy of the information
provided by the patients. The healthcare organization is responsible for securing the data
gathered during the registration step.
Charge capture- The HMIS department typically performs the charge capture step within a
healthcare organization. The front desk personnel within the organization is normally responsible
for inputting all necessary information about the patients and how much they will be charged for
the services.
Claim submission- The accounting department normally performs this step within the
healthcare organization. The department is responsible for sending information to the insurance
company for each of the respective patients concerning the charges for their services. If different
services were issued to the patient, those services should be submitted separately.
Remittance processing- This step includes the insurance carrier sending back information to the
healthcare organizations specifying the type of charges they have paid for. The steps are also
associated with determining any possible allowable. Negotiations between the healthcare
organization and the insurance carrier normally occur during this step, including the charges for
each service offered.
Insurance follow-up- This step includes the accounts department of the healthcare organization
checking the accounts receivables to determine the amount of money paid by the insurance
carrier. The primary aim of this step is to determine the type of services which still need to be
paid for by the insurance carrier.
Patient collections- The finance department normally performs this step within the healthcare
organization. It is important to understand that the providers normally collect money from the
patients when they are still within the organization.
Section 2
a. Monitoring crucial data by healthcare organization
All departments within a healthcare organization must ensure that the payments received
reflect the type of services the patients receive. Therefore, the data should be accurately
monitored. Failure to monitor crucial data by healthcare organizations consequently reduces the
amount of money received from insurance carriers (Das & Gonzalez, 2020). Additionally, failure
to monitor the data can also result in various errors during financial computations. Failure to
collect the correct amount of money will then mean that the services offered by the healthcare
organization will drastically reduce since they can no longer fund the services.
It is always recommendable to collect data for pay-for-performance incentives. That is
mainly because they can serve as an approach for assessing the healthcare organization’s goals.
All departments within a healthcare organization have their respective goals, and measuring the
pay-for-performance incentives can assist in determining how such goals can be achieved. The
data collected will be used to compare the performance of the veracious departments before the
pay-for-performance incentives and after they have been introduced.
b. Activities within each department
One of the most critical departments within a healthcare organization that impacts
reimbursement is the clinical service department. The activities performed by this department
include recording all necessary information about the patients and the type of services received
from the healthcare organization. Other information recorded by the department about the
patients includes their demographic information (Salvatore et al., 2021). Therefore, the accuracy
of the information collected by the department is paramount since other parties will use the same
A key data that should be reviewed during the reimbursement to determine whether there are
any changes needed is the chargemaster which plays a significant role in collecting and recording
any necessary information concerning the transactions made by the patient. Therefore, the
accuracy of the chargemaster is critical in ensuring that the accuracy of all other information is
maintained. If the accounting department delays developing a patient’s chart, including their
financial transactions, that will consequently result in delays in the reimbursement.
c. Departments for billing and coding policies
A critical department responsible for billing and coding policies is the administration
department. The department checks whether the regulation standards have been met during the
reimbursement process. The department impacts reimbursements within the organization by
maintaining the effectiveness of the process. That is primarily because of the effective adherence
to the set systems and policies.
Chalasani, S., & Koritala, S. (2019). An integrated case to teach healthcare reimbursement.
Business Education Innovation Journal, 11(1), 230-240.
Das, L. T., & Gonzalez, C. J. (2020). Preparing telemedicine for the frontlines of healthcare
equity. Journal of General Internal Medicine, 35(8), 2443-2444.
Salvatore, F. P., Fanelli, S., Donelli, C. C., & Milone, M. (2021). Value-based healthcare
principles in healthcare organizations. International Journal of Organizational Analysis.

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