Reimbursement Methods Project

Scenario

You are a manager in the billing department for Kent Valley Health System. Your system offers multiple healthcare services, including hospital inpatient and outpatient care, outpatient clinics, physician practices, and home health services. Your healthcare network is currently working on a strategic plan for the following year, and your supervisor has asked you to contribute to the planning process. As part of the strategic plan, your healthcare system has a goal to maximize reimbursement and thereby increase revenue. To begin the investigation into the healthcare network’s reimbursement practices, your supervisor would like to take a step back. He has asked you to analyze two reimbursement methodologies currently used by the healthcare system and its network, and then provide a report to him on what these methods are and how they impact the healthcare system. The research you conduct will guide the strategic planning team to analyze the healthcare system’s reimbursement processes, ensure that all provided services are billed, and minimize penalties from unachieved value-based purchasing criteria.

Directions

Your supervisor asked you to prepare a report analyzing two reimbursement methods currently used by the healthcare system. He has asked that you analyze both the fee-for-service reimbursement methodology and the pay-for-performance reimbursement methodology, which is a type of value-based purchasing. Your supervisor needs you to analyze the impact of the methodologies on the hospital and on employed physician practices who bill fee-for-service, but must also consider the Merit-based Incentive Payment System (MIPS) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This report will inform a deeper analysis of the healthcare system’s reimbursement processes and the strategic planning for the upcoming year as it relates to the system’s financial health.

Specifically, you must address the following:

  • Describe the steps a healthcare entity should follow in the revenue cycle to ensure it is billing appropriately for every service.
  • Describe the steps a healthcare entity can take to ensure it meets the value-based criteria to maximize reimbursement.
  • Define the fee-for-service reimbursement methodology, and explain the impact of the methodology on physician and outpatient services. Consider the following:
    • How does this methodology impact the revenue cycle?
    • Does the impact differ between an outpatient clinic and a physician practice?
    • Does the impact differ between government-sponsored programs and private insurance?
  • Define the pay-for-performance reimbursement methodology, and explain the impact of the methodology on healthcare entities. Consider the following:
    • How does this methodology impact the revenue cycle?
    • Does the impact differ between a hospital, an outpatient clinic, and a physician practice?
    • Does the impact differ between government-sponsored programs and private insurance?
  • Describe the impact value-based purchasing reimbursement requirements have on clinical programs to improve quality of patient care. Consider the following:
    • What requirements have been placed on hospital-acquired conditions and readmission rates over time? How do these requirements relate to the quality of patient care?
    • How have electronic health requirements impacted quality of patient care?
    • How have programs such as MIPS and MACRA impacted quality of patient care?
  • Describe how the relationship between the fee-for-service methodology and pay-for-performance methodology has impacted both reimbursement and patient care in healthcare entities.
    • What are the similarities and differences between how the fee-for-service methodology and pay-for-performance methodology impact healthcare entities?
    • How do the fee-for-service methodology and pay-for-performance methodology work together to impact reimbursement in healthcare entities, as well as quality of patient care?

What to Submit

Reimbursement Strategic Planning Report
Analyze the impact of the fee-for-service reimbursement methodology and the pay-for-performance reimbursement methodology on healthcare entities. Your report must be 750 to 1,250 words in length and cite any references.

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