Reference no: EM13465614

Section A

This task will allow you to examine the complexity of the healthcare reimbursement systems and begin to compare the similarities and differences between them. To complete this task, read the attached "A Lifetime of Healthcare Services," which is a case scenario about a woman named Sophie. Then create a multimedia presentation, diagram, table, or other illustration comparing the differences and similarities among the various insurance options and reimbursement systems that were used to pay for Sophie's medical care throughout her lifetime.

You are explaining these reimbursement systems from the perspective of a billing department manager training two new staff members. You believe that if you can explain these systems with a real patient, it will be easier for your new staff to understand the various requirements of these reimbursement systems.

A. Compare Sophie's health insurance options for each of the five phases of her life.

1. Recommend the health insurance option that would provide the best coverage to meet Sophie's needs during each phase.

a. List the elements of each plan you recommended.

b. Discuss the reimbursement requirements of each plan you recommended.

c. Discuss restrictions to each plan you recommended.

B. When you use sources, include all in-text citations and references in APA format.

Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the General Instructions section.

A Lifetime of Healthcare Services

Phase 1

When Sophie was first married, her husband worked in a meat packing plant. His job offered an optional health insurance package that could cover Sophie's husband, Sophie, and their family. Sophie did not have a job; she stayed home to care for their five children and an elderly parent. Many years passed. Sophie and her husband raised their children, and her elderly parent died. Sophie's husband looked forward to retirement.

Phase 2

Sophie's husband died before he reached retirement age. His company offered his benefits plan to Sophie, which she could enroll in indefinitely if she chose to do so. This plan would include good drug benefits. The insurance plan through the company had become a managed care plan over the years. Sophie decided to remain with her husband's insurance plan.

Phase 3

Sophie turned 65. She was on a tight budget and did not like the idea of paying a monthly premium. However, she wanted her insurance to provide many physician and service options. She also wanted a good drug coverage plan.

Phase 4

Sophie's health declined. She was hospitalized for several days after a fall and received home healthcare for several weeks. She was diagnosed with Alzheimer's disease about a year later and could no longer safely live alone. Sophie moved into an assisted living facility, and her daughter took over the financial management of her assets. In addition to other financial obligations, Sophie needed to pay for the cost of rent for the facility.

Phase 5

As Sophie's Alzheimer's disease progressed, she needed more nursing care than was available at the assisted living facility. Sophie's doctor recommended a skilled nursing facility for her continued care. At the nursing facility, she received nursing care, help with activities of daily living, and recreational therapy. This facility, too, required a rent payment. Sophie was transferred to the skilled nursing facility from her previous assisted living facility. After the first year, all of Sophie's financial resources were exhausted.

Section B.

Create a multimedia presentation (suggested length of 12-15 slides) in which you do the following:

Note: Your multimedia presentation may use various forms of visual aids and organizational patterns (e.g., charts, graphs, tables).

A. Discuss the quality reporting systems sponsored by Centers for Medicare and Medicaid Services (CMS) by doing the following:

1. Discuss the goals of quality reporting systems in healthcare organizations.

2. Compare the advantages and disadvantages of quality reporting systems.

3. Compare different quality reporting systems models currently used.

4. Illustrate the role of HIIM staff in participating in value-based purchasing as one of the quality reporting systems.

B. Present important legal points pertaining to compliance and reimbursement by doing the following:

1. Illustrate how the False Claims Act pertains to healthcare providers.

2. Summarize the criminal statutes regarding Medicare funding.

a. Illustrate how specific criminal statutes regarding Medicare funding pertain to healthcare providers.

3. Compare the Sherman Act, the Clayton Act, and the Federal Trade Commission Act.

a. Discuss the importance of these acts to healthcare providers.

4. Compare Stark II and the anti-kickback statute of the Medicare and Medicaid Protection Act of 1987.

a. Discuss the importance of these statutes to healthcare providers.

C. When you use sources, include all in-text citations and references in APA format.

Section C

In this task, you will describe various components of the coding and billing continuum and how errors may delay reimbursement or result in concerns of fraudulent practice. You will be required to discuss how several specific government directives have impacted healthcare organizations.

Task:

A. Evaluate the importance of the following government initiatives as they pertain to the coding function:

1. Medicare and Medicaid Patient and Program Protection Act of 1987

2. Operation Restore Trust

3. Medicare Integrity Program

4. Medicare Prescription Drug Improvement and Modernization Act of 2003: Recovery Demonstration Project

B. Explain the role of a quality improvement organization contracting under the Centers for Medicare and Medicaid Services as it applies to the coding process.

C. Diagram the activities of each step of the revenue cycle in the order in which they occur.

1. Describe the work of HIM staff members during each step of the revenue cycle in which they would be involved.

D. Illustrate how you would address the following automated billing report errors:

1. The date of service on one portion of the bill for a same-day surgery was not in agreement with the date on other portions of the bill

2. The diagnosis and procedural codes were inaccurate

3. A procedure was billed to the wrong patient

E. When you use sources, include all in-text citations and references in APA format.

Section D

There are many factors to be considered when examining organizational finances and making decisions that have long-term effects on a medical practice. In healthcare organizations, there are multiple payers that influence reimbursement. There are external agencies such as the federal or state government, which may set rate limits that impact revenues, and there are outside forces such as marketing structure and competition that influence pricing of healthcare services. Managers who oversee budgets and help to make financial decisions need an overall understanding of the forces shaping this environment.

Read the attached "Financial Resource Management and Healthcare Reimbursement." For this task, you will act in the role of the manager as you consider how to develop a financial plan for the clinic for the upcoming fiscal year, including projections for the future.

Task:

A. Create an agenda to present to Dr. Ross in a preliminary meeting with him before meeting with the entire physician group.

1. Summarize the types of financial information the physician group would need to understand to have a clear picture of the clinic's current financial status.

a. Discuss what is influencing the pricing for the pediatric services.

b. Discuss what is influencing revenue collection.

c. Illustrate how this information should be analyzed to assist in the decisions to be made for the practice.

B. Explain how issues presented in the scenario may impact the future revenue of the practice by doing the following:

1. Discuss the consideration to be given to the pediatric endocrinologist's request.

2. Discuss the aspects that need to be considered in adding pediatric oncology.

3. Present the components that should appear in a managed care contract with Indian Health Service.

C. Discuss how you could develop a financial plan for the clinic using a management control process for the budget implementation.

D. When you use sources, include all in-text citations and references in APA format.

Financial Resource Management and Healthcare Reimbursement

You are the manager of a pediatric private practice. The practice is owned by five pediatricians practicing full time. They all share in the call schedule. A visiting pediatric endocrinologist travels from out of state once a month to have a clinic one day with your patients. One of the practice pediatricians specializes in pediatric cardiology and sees patients who travel to your clinic from within the region.

You have identified financial concerns that you have been observing in the past year. There has been an increase in Medicaid patients and children enrolled in the State Children's Health Insurance Program (SCHIP). This change in your payer mix has resulted in a decrease in reimbursement, resulting in a decrease in quarterly disbursement to the physicians. You still have many patients covered by their parents' private insurance, most of which are managed care plans.

Recently, the pediatric endocrinologist spoke with you about receiving a raise. His expenses are fully covered by the clinic, and he bills out directly for his services. He is now requesting a stipend in addition to his regularly covered services. You told him he would need to speak with Dr. Ross, who started the practice ten years ago, but that you believe his remuneration is already reasonable and fair.

Several of the partners have approached you separately about ideas they have for increasing clinic services. One partner would like to contract with a pediatric oncologist from another area of the state. The partner believes that if the pediatric oncologist were brought in for a monthly clinic day, as the pediatric endocrinologist is, this could bring in another source of revenue.

Another one of the pediatricians heard that the contract for Indian Health Service was up for renewal soon. The pediatrician suggested that this was a patient population that could be served through outreach, that is, one or two of the pediatricians could travel to the clinics at the reservations to treat patients, or patients could come to the clinic. This would also be a new revenue stream.

You decide to meet with Dr. Ross to discuss having a meeting with all the partners about strategic financial planning for the coming fiscal year, along with long-range plans for the next five years.