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HCM 345 Milestone One Guidelines and Rubric
Overview: Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization.
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.
From the moment you make an appointment to see your physician, the provider needs to track all of the financial elements involved in providing care. Medical
billing software is one component utilized to track the financial elements, from verifying insurance coverage and determining copayments, as well as sending
claims electronically to various third-party payers. Revenue cycle management (RCM) describes the combined administration of these essential financial
processes.
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 are
exposed to the necessary knowledge.
In Milestone One, you will take a closer look at how reimbursement impacts other healthcare departments, and you will dive deep into analyzing the revenue
cycle, utilizing data, tracking records, and ensuring compliance within individual departments.
Pay-for-performance is a requirement for Medicaid Managed Care, Medicare, and commercial plans, requiring reporting on quality outcomes.
Prompt: Submit a draft of Sections I and II of the final project. Specifically, the following critical elements must be addressed:
I. Reimbursement and the Revenue Cycle
a. Describe what reimbursement means to a healthcare organization. What would happen if services were provided to patients but no payments
were received for those services?
b. Illustrate the flow of the patient through the cycle from the initial point of contact through the care and ending at the point where the payment
is collected.
II. Departmental Impact on Reimbursement
a. Many different departments utilize reimbursement data in a healthcare organization. It is crucial the healthcare organization monitors this data.
What impact could the healthcare organization face if this data were not monitored? Describe why collecting data is required for pay-forperformance incentives.
b. Describe the activities within each department in a healthcare organization for how they may impact reimbursement. What specific data would
you review in the reimbursement area to know whether changes were necessary?
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c. Identify the responsible department for ensuring compliance with billing and coding policies. How does this affect the department’s impact on
reimbursement in a healthcare organization?
Rubric
Guidelines for Submission: Your paper must be submitted as a 3- to 4-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
Reimbursement and
the Revenue Cycle:
Reimbursement
Comprehensively describes what
reimbursement means to a healthcare
organization
Describes what reimbursement means to a
healthcare organization, but description is
not comprehensive or contains errors
Does not describe what reimbursement
means to a healthcare organization
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Reimbursement and
the Revenue Cycle:
Flow of the Patient
Accurately illustrates the flow of the
patient through the revenue cycle
Illustrates the flow of the patient through
the revenue cycle, but illustration is unclear
or inaccurate
Does not illustrate the flow of the patient
through the revenue cycle
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Departmental Impact
on Reimbursement:
Departments
Comprehensively describes the impact
of the departments that utilize
reimbursement data and also influence
reimbursement at a healthcare
organization
Describes the impact of the departments
that influence reimbursement, but
description is not comprehensive or is not
specific to departments that utilize
reimbursement data
Does not describe the impact of the
departments that influence
reimbursement at a healthcare
organization
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Departmental Impact
on Reimbursement:
Activities
Describes the activities within each
department at a healthcare organization
for how they impact reimbursement
Describes the activities within each
department at a healthcare organization
but does not explicitly link these activities
to reimbursement, or assessment is not
specific
Does not describe the activities within
each department at a healthcare
organization for how they may impact
reimbursement
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Departmental Impact
on Reimbursement:
Responsible
Department
Correctly identifies the department
responsible for ensuring compliance of
billing and coding policies and its impact
on reimbursement at a healthcare
organization
Identifies the department responsible for
ensuring compliance of billing and coding
policies and its impact on reimbursement
at a healthcare organization, but
identification is incorrect
Does not identify the department
responsible for ensuring compliance of
billing and coding policies
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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
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Total 100%