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APA
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Health, Medicine, Nursing
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English (U.S.)
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Topic:

Describing Reimbursement and the Revenue Cycle

Essay Instructions:

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.
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.
Milestone One provides you an opportunity to engage with real-world data that you would encounter in an actual professional environment. Specifically, 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.
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. Also identify the departments in order of importance to the revenue cycle.
II. Departmental Impact on Reimbursement
a. Describe the impact of the departments in a healthcare organization that utilize reimbursement data. What type of audit would be necessary to
determine whether the reimbursement impact is reached fully by these departments? How could the impact of these departments on pay-for-
performance incentives be measured?
b. Assess 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?
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?

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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?
Healthcare reimbursement is the process by which healthcare providers receive payments for the services rendered to patients. the healthcare providers receive the payments either from the government, i.e., Medicare or private insurance providers CITATION Chr18 \l 1033 (Rosario, 2018). Healthcare reimbursements are important to the health facility because it is the revenue stream to fund operations and profits for shareholders. Although doctors, nurses, and all other staff have to be paid, mostly the income to the facility comes from reimbursements. Other than human resource costs, utility bills such as water and electricity are billed to the health facility. Drugs and the cost of acquiring, running, and maintaining hospital equipment also have to be met. Without reimbursements, health facilities would not be able or struggle to dispense quality health services to patients.
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. Also, identify the departments in order of importance to the revenue cycle.
Departmental Impact on Reimbursement
a. Describe the impact of the departments in a healthcare organization that utilizes reimbursement data. What type of audit would be necessary to determine whether the reimbursement impact is reached fully by these departments? How could the impact of these departments on pay-for-performance incentives be measured?
When departments utilize reimbursement data, they can manage and fine-tune their reimbursement processes to run efficiently and with fewer denials or shortfalls CITATION Ric14 \l 1033 (Shrader, 2014). For example, if reimbursement data is analyzed to understand the reasons for many denials, the administration can improve its documentation process to reduce denials. Additionally, reimbursement data can be used to improve the value offered to patients as they can assess and trim unnecessary procedures that are easily denied in claims. Thus, reimbursement data helps the department run efficiently and effectively to benefit the patient, the provider, and the payer.
An internal audit can be an effective process to help healthcare providers streamline their reimbursement processes to run efficiently and in line with the department's goals...
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