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Reimbursement

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1

HCM 345 Milestone Two Guidelines and Rubric

Overview: Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the o rganization.
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 a re exposed to the
necessary knowledge.

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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. 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.

2

Rubric
Guidelines for Submission: Your draft must be submitted as a 3- to 5-page Microsoft Word document with double spacing, 12-point Times New Roman font,
one-inch margins, and at least three sources, which should be cited in APA format.

Critical Elements Proficient (100%) Needs Improvement (75%) Not Evident (0%) Value

Billing and
Reimbursement: Third-

Party Policies

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

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

Does not analyze how third-party policies
would be used

12.5

Billing and
Reimbursement: Key

Areas of Review

Organizes and explains the key areas of
review in order of importance for
timeliness and maximization of
reimbursement from third-party payers

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

Does not organize and explain the key
areas of review in order of importance for
timeliness and maximization of
reimbursement from third-party payers

12.5

Billing and
Reimbursement:

Structure

Describes a way to structure follow-up
staff in terms of effectiveness and
explains rationale for effectiveness

Describes a way to structure follow-up staff
in terms of effectiveness but does not explain
rationale for effectiveness

Does not describe a way to structure
follow-up staff in terms of effectiveness

12.5

Billing and
Reimbursement: Plan

Develops a plan for periodic review of
procedures to ensure compliance,
including explicit steps and the
feasibility of enacting the plan

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

Does not develop a plan for periodic
review of procedures to ensure
compliance

12.5

Marketing and
Reimbursement:

Contracts

Explains how new managed care
contracts impact reimbursement for
the healthcare organization, including
support for explanation with concrete
evidence or research

Explains how new managed care contracts
impact reimbursement for the healthcare
organization but does not include support for
explanation with concrete evidence or
research

Does not explain how new managed care
contracts impact reimbursement for the
healthcare organization

12.5
Marketing and
Reimbursement:

Compliance

Comprehensively discusses the
resources needed to ensure billing and
coding compliance with regulations and
ethical standards

Discusses the resources needed to ensure
billing and coding compliance with
regulations and ethical standards, but
discussion is not comprehensive

Does not discuss the resources needed to
ensure billing and coding compliance

12.5

Marketing and
Reimbursement: Ethical

Standards

Thoroughly evaluates various strategies
for ensuring stakeholders adhere to
ethical standards during the process

Evaluates various strategies for ensuing
stakeholders adhere to ethical standards
during the process, but the analysis not
supported with concrete evidence or
research

Does not evaluate any strategies for
ensuring stakeholders adhere to ethical
standards during the process

12.5

3

Critical Elements Proficient (100%) Needs Improvement (75%) Not Evident (0%) Value

Articulation of
Response

Submission has no major errors related
to citations, grammar, spelling, syntax,
or organization

Submission has major errors related to
citations, grammar, spelling, syntax, or
organization that negatively impact
readability and articulation of main ideas

Submission has critical errors related to
citations, grammar, spelling, syntax, or
organization that prevent understanding of
ideas

12.5

Total 100%

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