The Revenue Cycle Process and REIMBURSEMENT MODELS

1:

• Develop a 10-slide PowerPoint presentation with accompanying 10 to 20 minutes of audio targeted at educating new hires at a health care organization about the revenue-cycle process.
  

  Introduction

  The financial health of the health care organization depends upon its ability to generate consistent and recurring funds from the services it provides. Collectively referred to as the revenue cycle (RCM), critical stages in this process include:

  • Patient registration.
  • Collection of demographics and payor source.
  • Rendering services.
  • Documenting services.
  • Establishing charges.
  • Preparing the claim or bill.
  • Submitting the claim.
  • Receiving payment.
  • Managing accounts receivable.

  Decreasing payment delays and lost revenues is a point of interest for many health care managers tasked with oversight of the RCM process. Innovative approaches in technology have assisted with streamlining the RCM process and allowed for automation of many processes, resulting in expedited processing and quick remittance.Managed care dollars represent a significant portion of all health care organizations’ reimbursements. As a result, health care organizations seek to establish contracts with large managed care organizations (MCOs). Negotiating and securing contracts with MCOs is important for several reasons, including preserving revenues, enhancing patient satisfaction, and generating additional sources of revenue.All contracts will contain language outlining the administration of the contract along with the payment schedule. While the payment schedule may be seen as the most important element, the terms outlined within the contract are equally as vital to the financial success of the organization.This assessment focuses on the revenue cycle and how technological innovations have impacted reimbursement for health care organizations. You will take on the role of a patient access supervisor. One of your job functions entails educating new hires on the revenue cycle process.

  Demonstration of Proficiency

  By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 3: Explain the organizational revenue cycle process.
    • Identify key steps of the revenue cycle process.
    • Explain the purpose of each identified step in the revenue cycle process.
    • Describe key components of each function in the revenue cycle process.
    • Explain the consequences of failing to conduct the function identified.
    • Explain additional steps and challenges in the revenue cycle process when working with an uninsured patient.
  • Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
    • Demonstrate effective communication through writing and proper use of APA style with no significant errors, and supports analysis and recommendations with appropriate current literature.

  Instructions

  For this assessment, prepare a 10-slide PowerPoint presentation outlining the various steps of the revenue cycle. For the scenario, imagine you are a patient access supervisor who must educate a group of new hires about the revenue cycle process, including:

  • The revenue cycle process.
  • Their potential responsibilities.
  • Why the process is important to a care organization.
  • Challenges that they may face in their work.

  Record audio for this presentation. You can record directly into your PowerPoint presentation, or through Kaltura. You may wish to consult these resources before starting your assessment:

  • Guidelines for Effective PowerPoint Presentations [PPTX].
  • Using Kaltura [PDF].

  Before you begin, be sure to review the scoring guide. When structuring your presentation, consider the following points and questions to ensure that you are meeting the scoring guide criteria:

  • Identify the various steps within the revenue cycle process, including admissions, case management, documentation, coding, billing, et cetera.
  • Provide the following for each step identified:
    • Purpose of the step identified.
    • Responsible functions completed by individuals, such as coders, registration clerk, et cetera.
    • Key components of the function, such as verifying insurance, financial counseling, or coding of documented services provided.
    • Consequences of failure to properly conduct the function identified.
  • Provide information for the new staff regarding options available for the uninsured.
  • Identify any additional steps throughout the revenue cycle one must be aware of when working with an uninsured patient.
  • Identify the challenges that exist for the revenue cycle due to the delivery of uncompensated care.

  Additional Submission Requirements

  • Communication: Communicate in a manner that is scholarly, professional, respectful, and consistent with expectations for professional practice in education. Original work and critical thinking are required regarding your assessment and scholarly writing. Your writing must be free of errors that detract from the overall message.
  • Media presentation: Create 10 slides you would present in 10 to 20 minutes, plus an APA-formatted Reference slide at the end of the presentation.
  • Resources: Cite at least three scholarly resources.
    • Your textbook can be one of the three.
  • APA guidelines: Use APA style for references and citations. When appropriate, use APA-formatted headings. For more information, refer to the APA resources located in the courseroom navigation panel.
  • Font and font size: Times New Roman, using appropriate size and weight for a presentation, generally 24–28 points for headings and no smaller than 18 points for bullet-point text.

  2:

  • Develop a two-page memo to help relevant stakeholders at Vila Health’s St. Anthony Medical center better understand traditional and emerging reimbursement models.

    Introduction

    Note: This assessment uses the following media piece as the context for developing the reimbursement model memo. Review this media piece before you submit your assessment.

    • Vila Health: Investigating a Readmission | Transcript.

    Basic understanding of the reimbursement system requires one to appreciate the size and scope of the system, the complexities associated with the system, and the various subsystems and payment rules associated with health care reimbursement and finance. As a dominant player in the health care sector, the U.S. federal government is the largest single payer for health care services. As a result of its size and dominance within the system, any changes made by the federal government regarding its reimbursement of health services profoundly affect those who are rendering the care, including providers, other payers, and the health system overall. In addition to government-sponsored health insurance, various other forms of health coverage, generally tied to employment as a benefit, were introduced in the United States to help offset the expenses associated with the treatment of illness and injury.

    In an effort to address concerns within the U.S. health system regarding cost, access, and quality, Congress passed the Patient Protection and Affordable Care Act (PPACA or ACA) in 2010, with President Barack Obama signing it into law. Components of the PPACA included making health insurance coverage affordable, expanding Medicaid coverage, and improving quality while controlling costs. To this end, the ACA required the Centers for Medicare and Medicaid (CMS) to promote the concept of the accountable care organization (ACO) through a shared savings plan driven by a triple-aim approach. In addition to the ACO, the ACA required CMS to implement value-based purchasing programs that would reward hospitals for the quality of care they provided to enrollees.

    As the recipient of the largest share of Medicare funds, the new value-based purchasing approach measures hospital performance using four domains:

    1. Clinical care.
    2. Safety.
    3. Efficiency and cost reduction.
    4. Patient experience of care (Casto & Forrestal, 2015, p. 305).

    Each measure scores the hospital performance achievement as well as their performance improvement.

    As a health care sector employee, understanding the complex U.S. health care reimbursement system allows one to serve as a reference to internal and external stakeholders, family members, and organizational departments whose needs often require a working knowledge of how the system is financed.

    In this assessment, you demonstrate your understanding of traditional and emerging health care reimbursement models by composing a memo that outlines the characteristics and differences between reimbursement models. This memo targets relevant stakeholders from the Vila Health media simulation based in St. Anthony Medical Center.

    Reference

    Casto, A. B., & Forrestal, E. (2015). Principles of healthcare reimbursement (5th ed.). Chicago, IL: AHIMA Press.

    Demonstration of Proficiency

    By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

    • Competency 1: Compare current trends and traditional methods of payment in the health care industry.
      • Describe traditional payment methods in health care, such as fee-for-service or capitated payment.
      • Describe current trends in health care payment, such as value-based or accountable care organizations.
      • Describe the difference in reimbursement between traditional and newer models of reimbursement in a specific patient scenario.
    • Competency 2: Assess health care reimbursement.
      • Compare and contrast how quality outcomes are rewarded under traditional and current payment methodologies in health care.
      • Explain reasoning for newer models of reimbursement in health care.
      • Identify quality concerns affecting reimbursement given a specific patient scenario.
    • Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
      • Demonstrate effective communication through writing and proper use of APA style with no significant errors, and supports analysis and recommendations with appropriate current literature.

    Instructions

    Several of the Vila Health’s stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. For this assessment, prepare a two-page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.

    Support your assertions in the memo with at least three academic sources. This may require you to do additional independent research. You may wish to consult the
    Health Care Administration Undergraduate Library Research Guide before you begin any additional research.

    This assessment has four main parts. Before you begin, be sure to review the scoring guide for this assessment.

    Part 1: Traditional Reimbursement Models

    Describe traditional reimbursement models like fee-for-service or capitated payments. You might want to consider the following when developing this part:

    • What are the key characteristics of these reimbursement models?
    • How was quality monitored under these models?
    • How was quality rewarded under these models?

    This part should be at least one paragraph long, but probably no more than half a page.

    Part 2: New Reimbursement Models

    Describe current trends in reimbursement models like accountable care organizations or value-based payments. You might want to consider the following when developing this part:

    • What are the key characteristics of these reimbursement models?
    • How was quality monitored under these models?
    • How was quality rewarded under these models?

    This part should be at least one paragraph long, but probably no more than half a page.

    Part 3: Comparison of Models

    Develop a concise comparison of the key similarities and differences of the reimbursement process between traditional and current models. Also, include considerations related to the role of quality in reimbursement, and why it might be included in newer models.

    This part should likely be between a half and one page long.

    Part 4: Quality Concerns

    Specifically address the recent problematic patient case from the Vila Health: Investigating a Readmission scenario. Briefly discuss how the care provided would be reimbursed under prior models versus reimbursement under newer models, based on your assertions in Part 3 of your memo. Also, identify quality issues that will likely impact the organization’s reimbursement under new payment models.

    This part should be at least one paragraph long, but probably no more than half a page.

    Additional Submission Requirements

    • Structure: Structure your submission like a memo, with an additional, APA-style References page. You may wish to refer to the following example when developing your memo:
      • Sample Memo.
    • Length: 1–2 pages, plus a References page.
    • References: Cite at least three current scholarly or professional resources.
      • Your textbook can be one of the three.
    • Format: Use APA style for references and citations only. Refer to:
      • APA Style Paper Template [DOCX].
      • APA Style Paper Tutorial [DOCX].
      • Additional APA resources located in the courseroom navigation panel.
    • Font: Times New Roman, 12 point, double-spaced.

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