UNIT 1
Create a 2-3 page memorandum (excluding Reference page) for Vila Health stakeholders that compares older and newer reimbursement models and informs stakeholders about how each model would impact their organization.
Note: This assessment uses the following media as the context for developing the reimbursement model memo. Review this media before you submit your assessment.
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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 affects 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 & 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:
- Clinical care.
- Safety.
- Efficiency and cost reduction.
- Patient experience of care ().
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 will 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
Data.CMS.gov. (n.d.). Linking quality to payment. U.S Centers for Medicare & Medicaid Services.
You will use as the context to address parts of this assessment.
Several of Vila Health’s stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. For this assessment, prepare a 23 page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.
Use the to help structure each section of your memo. 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 before you begin any additional research.
In your memo, address each of the following scoring guide criteria:
- Describe traditional payment models in health care.
- Describe means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
- Identify the traditional payment models.
- What are the key characteristics of these reimbursement models?
- How was quality monitored under these models?
- This part should be at least one paragraph long, but probably no more than half a page.
- Describe current trends in health care payment models.
- Identify the current trends in health care payment models.
- What are the key characteristics of these reimbursement models?
- How is quality monitored under these models?
- This part should be at least one paragraph long, but probably no more than half a page.
- Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
- Develop a concise comparison of the key similarities and differences of the reimbursement process between traditional and current models.
- This part should likely be between a half and one page long.
- Describe quality concerns affecting reimbursement given a specific patient scenario.
- 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 assertions you made in the previous section 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.
- Adhere to the rules of grammar, usage, and mechanics.
- Grammar refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
- Usage refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
- Mechanics refers to correct use of capitalization, punctuation, and spelling.
- Apply APA formatting to in-text citations and references.
UNIT 2
Write a 3-5 page paper (excluding Title and Reference pages) that describes the various provider reimbursement options for both insured and uninsured patients in a large primary care office.
Reimbursement for services rendered by providers (physicians, physician assistants, and other providers) is generally made under one of two payment types: fee-for-service or episode of care reimbursement. Fee-for-service methodology is based on the premise that providers receive payment for each service rendered and is based on a set amount or price for each service. Included in this methodology are self-pay payments, retrospective payments, and managed care contracts.
Under the episode of care methodology, providers receive one lump sum for all services provided related to a given condition or disease. Understanding each method of payment, its benefits and drawbacks, as well as its impact on cost control and resource utilization is important for those working in the health industry, as reimbursement impacts many decisions made about budgets, forecasts, strategy, and service line capacities.
In this assessment, you will demonstrate your understanding of various reimbursement options within the context of a new patient consult. For this assessment, assume the role of a reimbursement specialist for a large primary care office. While you are aware that your providers are reimbursed in several different ways, the providers are uncertain as to what each reimbursement type means for the practice in terms of collections. They have requested that you outline the different reimbursement options to which the practice is subject for the providers in the group.
This assessment is based on the following scenario:
- Patient scenario: Your office is seeing a new patient for the first time (new patient consults are $500).
In your role as the reimbursement specialist for a large primary care office, outline the different reimbursement options to which the practice is subject for the providers in the group.
Use the to help structure your assessment. Support your assertions with at least three academic sources. This may require you to do additional independent research. You may wish to consult the and before you begin any additional research.
This assessment has two parts.
Part 1: Provider Reimbursement Options
Present (at least) the four main reimbursement options that your provider in the scenario would likely have for a new patient consult. Describe the options and comment on potential drawbacks or additional considerations to take into account with each model. Also, consider the likelihood and challenges of recouping the entirety of the consult charges for the patient.
Relevant scoring guide criteria:
- Describe drawbacks of the fee-for-service reimbursement model.
- Describe means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
- Describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services.
- Describe how pay-for-performance impacts reimbursement rates.
- Describe how resource-based relative value scale or case-based payment encourage an overuse of services.
- Adhere to the rules of grammar, usage, and mechanics.
- Grammar refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
- Usage refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
- Mechanics refers to correct use of capitalization, punctuation, and spelling.
- Apply APA formatting to in-text citations and references.
- Be sure to include a separate references page.
One potential way to organize this part would be as follows:
- Fee-for-service.
- What is it?
- Consider health care spending and cost control; what are the drawbacks of this model?
- Capitation.
- What is it?
- What are the potential drawbacks of this model for the physicians who are driven to provide comprehensive services to their patients?
- Pay for performance.
- What is it?
- How does this model impact reimbursement rates?
- Resource-based relative value scale or case-based payment.
- What is it?
- How can this model potentially encourage an overuse of services?
Part 2: Payment Options for Uninsured Patients
Identify and explain the potential payment options that would be available to the patient and your care provider if the patient in for the new patient consult had been uninsured. Also, be sure to discuss the ways that a patient could qualify for specific payment options, as well as the rationale for the associated appointment charge.
Relevant scoring guide criteria:
- Describe payment options for uninsured patients, including how the patient would qualify for each option.
- Adhere to the rules of grammar, usage, and mechanics.
- Apply APA formatting to in-text citations and references.
One potential way to organize this part would be:
- Medicaid.
- How does the patient qualify?
- Financing options.
- What is this method?
- Self-pay.
- How would the patient be charged? A percentage of commercial contracts or a percentage of Medicare
- Charity care.
- How would you screen a patient for charity care?
- What process would you implement to qualify a patient for charity care
UNIT 3 Create a 10-slide PowerPoint presentation, with Speaker Notes (and excluding Title and Reference slides), that outlines the stages of the revenue cycle process for a group of new hires, including the various stages, their responsibilities, and challenges they may face when working with a revenue cycle process.
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 about the revenue cycle process.
For this assessment, prepare a 10-slide (excluding Title and Reference slides) PowerPoint presentation, with Speaker Notes, outlining the various steps of the revenue cycle. Use the to help you structure your presentation.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.
When structuring your presentation, consider the following points and questions to ensure that you are meeting the following scoring guide criteria:
- Describe the purpose of each step in the revenue cycle process.
- Describe means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
- The steps within the revenue cycle process include admissions, case management, documentation, coding, billing, and other steps.
- Describe key responsibilities of individuals who work in the revenue cycle process.
- Describe key components (such as verifying insurance, financial counseling, coding of documented services provided, and other components) and who is responsible (individuals such as coders, registration clerks, and others).
- Describe the consequences to the organization of failing to fulfill key responsibilities in the revenue cycle process.
- Describe additional steps and challenges in the revenue cycle process when working with an uninsured patient.
- 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.
- Adhere to the rules of grammar, usage, and mechanics.
- Grammar refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
- Usage refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
- Mechanics refers to correct use of capitalization, punctuation, and spelling.
- With the exception of the title slide and the reference slide, each slide should contain detailed speaking notes.
- Apply APA formatting to in-text citations and references.
- Provide in-text citations within the speaking notes, just like you would in a paper, to show where the information was obtained.
- Be sure to include an APA-formatted Reference slide at the end of the presentation.
Submit your completed PowerPoint Presentation as an attachment in the assessment.