Scenario
You are an assistant to the reimbursement manager at Southern Valley Hospital. The manager recently hired quite a few new employees on the reimbursement team, and you have received many questions from the new employees about where to find current information on reimbursement practices. In addition, it has come to your attention that current employees are also unfamiliar with where they can find resources and information on changes that might impact reimbursement practices. You need to ensure that all employees on the team have the same base information about reimbursement, and so you have decided to create a reimbursement resources toolkit that guides employees around where to find specific resources that address current trends and updated information. In the toolkit, you will also provide real-world examples to show employees how to use the specific resources.
Directions
As the assistant to the reimbursement manager at Southern Valley Hospital, you are responsible for ensuring your team remains current on reimbursement practices and policies, enabling the hospital to remain in compliance with various guidelines and policies, and providing the organization the opportunity to maximize its reimbursement. To ensure the team has the appropriate knowledge, you have decided to develop a Reimbursement Resources Toolkit. This toolkit will provide details around the key elements that may impact Medicare, Medicaid, and private insurance, as well as identify resources that can be used to stay informed and current on these specific elements. In addition, you will provide specific examples to illustrate how to use the resources.
Specifically, you must address the following:
Medicare Reimbursement Resources
Describe key elements impacting Medicare legal and financial reimbursement practices. Consider the following:
How do prospective payment systems (PPSes) and Federally Qualified Healthcare Centers (FQHCs) impact reimbursement practices?
How is Medicare updating regulations and regulatory provisions, and how do these impact reimbursement practices?
How does coverage differ between various programs in Medicare?
Identify key sources from CMS.gov and Medicare.gov that can be used to stay current and informed of the previously identified legal and financial elements impacting reimbursement. Be sure to also briefly describe each resource and the information it provides.
Provide a specific, real-world example of how a healthcare professional in reimbursement might use one of the resources in his or her role, and explain the importance of ensuring the hospital is legally and financially current on the specific topic. For example, you might consider how staying legally and financially informed helps to maximize reimbursement, or describe some legal and financial repercussions of not staying current and informed.
Medicaid and CHIP Reimbursement Resources
Describe key elements impacting Medicaid and CHIP legal and financial reimbursement practices. Consider the following:
How might you stay informed of the status of a claim?
How might reimbursement procedures vary from state to state, and how does this impact reimbursement practices?
What are some updates that might take place to impact Medicaid and CHIP reimbursement? What are the implications of the timeline for updating internal practices?
Identify key sources from Medicaid.gov that can be used to stay current and informed of the previously identified legal and financial elements impacting reimbursement. Be sure to also briefly describe each resource and the information it provides.
Provide a specific, real-world example of how a healthcare professional in reimbursement might use one of the resources in his or her role, and explain the importance of ensuring the hospital is legally and financially current on the specific topic. For example, you might consider how staying legally and financially informed helps to maximize reimbursement, or describe some legal and financial repercussions of not staying current and informed.
Private Insurance Reimbursement Resources
Describe key elements impacting private insurance legal and financial reimbursement practices. Consider the following:
How do changes to the Patient Protection Affordable Care Act (PPACA) impact reimbursement?
How might insurance plans differ depending on employer?
How might private insurance differ depending on employer-based, self-pay, or Consolidated Omnibus Budget Reconciliation Act (COBRA)?
Identify key sources from The Center for Consumer Information & Insurance Oversight that can be used to stay current and informed of the previously identified legal and financial elements impacting reimbursement. Be sure to also briefly describe each resource and the information it provides.
Provide a specific, real-world example of how a healthcare professional in reimbursement might use one of the resources in his or her role, and explain the importance of ensuring the hospital is legally and financially current on the specific topic. For example, you might consider how staying legally and financially informed helps to maximize reimbursement, or describe some legal and financial repercussions of not staying current and informed.
What to Submit
Reimbursement Resources Toolkit
Describe key elements that may impact Medicare, Medicaid, and private insurance, and identify resources that can be used to stay informed and current on these specific elements. In addition, provide specific examples illustrating how to use the resources. Your toolkit must be 750–1,250 words in length and cite any references using the appropriate formatting guidelines.
Sources
Anne B. Casto, & Elizabeth Forrestal. (2013). Principles of Healthcare Reimbursement, 4th Edition: Vol. Fourth edition. AHIMA Press. Chapter 1 PP 3-7.
Anne B. Casto, & Elizabeth Forrestal. (2013). Principles of Healthcare Reimbursement, 4th Edition: Vol. Fourth edition. AHIMA Press. Chapter 2 PP 27-31.
Payne, B. K. (Academic). (2017). White-collar crime [Video]. SAGE Knowledge. https://dx.doi.org/10.4135/9781526400895
Anne B. Casto, & Elizabeth Forrestal. (2013). Principles of Healthcare Reimbursement, 4th Edition: Vol. Fourth edition. AHIMA Press. Chapter 1 PP 7-12
http://www.nachc.org/wp-content/uploads/2016/02/PPS-One-Pager-noask-Final.pdf
Anne B. Casto, & Elizabeth Forrestal. (2013). Principles of Healthcare Reimbursement, 4th Edition: Vol. Fourth edition. AHIMA Press. Chapter 4 PP 93-95
American Medical Association. (2017). Principles of CPT Coding: Vol. 9th Edition. American Medical Association. Chapter 11 PP 667-672
American Medical Association. (2017). Principles of CPT Coding: Vol. 9th Edition. American Medical Association. Chapter 12 PP 677-684
Anne B. Casto, & Elizabeth Forrestal. (2013). Principles of Healthcare Reimbursement, 4th Edition: Vol. Fourth edition. AHIMA Press. Chapter 4 PP 95-96
https://web.archive.org/web/20200106215640/https://www.medicaid.gov/medicaid/program-information/downloads/accomplishments-report.pdf (pp. 3–4, 9–16, and 25–27)
https://www.medicaid.gov/federal-policy-guidance/index.html
Louis Gapenski. (2016). Healthcare Finance: An Introduction to Accounting and Financial Management, Sixth Edition: Vol. Sixth edition. Health Administration Press. Chapter 2 PP 49-51
Anne B. Casto, & Elizabeth Forrestal. (2013). Principles of Healthcare Reimbursement, 4th Edition: Vol. Fourth edition. AHIMA Press. Chapter 3 PP 59-62
