Optimizing Regional Medical Center Reimbursements and Clinical Governance

Instructions
Case Scenario Analysis: you have been hired in the CAO's newly created position (Chief Administrative Officer) for a regional medical center. The responsibilities have been broken away from the COO (Chief Operational Officer) to focus primarily on all business and revenue generation activities.
The hospital is a nonprofit. The services provided within the hospital include cardiac rehabilitation, emergency department, radiology, pediatrics, same-day surgery, a retail pharmacy, ophthalmology and optical, oncology, limited physical rehabilitation, and physical therapy, patient education, substance abuse, renal dialysis, and obstetrics. The Joint Commission accredits the hospital with recertification in 2 years.
There are 30-35 full-time physicians and 10 mid-level providers (nurse practitioners and physician assistants). These professionals are not employees of the hospital but are affiliated with a contracted provider group.
The following specialties are located within the hospital: family medicine, radiology, emergency medicine, obstetrics and gynecology, internal medicine, ophthalmology, cardiology, diagnostic radiology, pediatrics, general surgery, and orthopedic surgery. Other specialty physicians are contracted with the state's largest medical center and teaching facility on a limited basis located about 100 miles away.
You are a member of the hospital's executive management team (Chief Executive Officer, Chief Operational Officer, Chief of the Clinical Staff (medical and nursing), Chief Information Officer, Chief Compliance Officer, and Chief Quality and Risk Management Officer, and legal counsel).
The CEO has appointed you to examine the current billing processes within the hospital to maximize reimbursements and submit a comprehensive analysis back to her with your findings and specific actions to address each one from an administrative viewpoint. You learned early that the CEO is thorough and bases her decisions on collaboration, data, facts, and legal authority with the two primary objectives of high-quality care, minimizing risk to the organization.
Your initial assessment determined an unanticipated element of concern regarding the coordination and processes between the clinical providers (physicians and midlevel providers) and the administration. The Chief of the Clinical Staff was excellent in addressing the clinical care provided; however, there was limited collaborative oversight to maximize revenue generation activities nor clinical and regulatory oversight at the executive level. You further determined the following:
1.The hiring and credentialing processes were seemingly sufficient and compliant with state and accreditation requirements; however, the credentialing process for traveling specialists was different from those of the full-time affiliated staff.
2.Inconsistent medical record documentation and, subsequently, billing practices, particularly by specialty with cardiology, orthopedic surgery, oncology, and emergency medicine along with traveling specialties.
3.The scope of care was, at times, extended beyond qualifications and credentials when there was a lack of specialists available for consultation or treatment. While it was initially thought to be isolated to mid-level providers, it extended into other physician specialties.
4.The clinical governance was inconsistent and typically ad hoc with limited review and enforcement of bylaws, peer reviews, or other federal regulatory requirements.
5. No medical malpractice claims were within the past 5 years.
TASK(S): Upon initial conversation with the CEO, she asked you to compose an inclusive memorandum of record back to her to address the following:
1. An examination into the role of clinical authority and its direct alignment to the business of healthcare for this hospital.
2. For each area you identified, propose collaborative solutions and process improvements the executive management team could move forward with based on current legal authority in your state (please research your state's requirements to incorporate into the case study) and compliance. In the recommendations, she is requesting a multidisciplinary team approach, so include – by hospital position – those at the hospital's senior and middle management levels you would recommend on the team.
3. Finally, present a proposal for clinical management and clinical governance, whether directly under the CMO, jointly between the CMO and CAO, or something different.
While a memorandum can be in any professional format, it is expected that content is original, founded in best practices, and scopes of care with all external authors had APA citation to the sources in the body and on the last page with an APA reference list.
Grading Criteria
Student writing should be at the academic level, unbiased language in the third person, and proper healthcare and legal vernacular.
Assigned papers will require APA formatting (most current edition), including the title and reference pages. If you are unsure how to format using APA style, please see the Writing Center or Syracuse Library Citation Guide: APA .
Excluding the APA title and reference pages, the papers should be between 1,000 - 1500 words in the body. The word count requires the substance to be concise, robust, logical, and demonstrate complete knowledge of the weekly content. Although not in proper APA formatting, please include the word count for the paper's body at the very bottom of the title page. For assistance with determining the word count, please see the following Microsoft Word resource.
The body of the paper should include first level APA headings for all content or topics when required. Having the required content as first-level headings will support students in meeting the content requirements and the paper's focus on the required subjects. Students are welcome to add subheadings at the second or third levels, but the first level is required. The APA Style Headings can assist with formatting headings.
All sources used within the paper's body (directly and paraphrased) must be cited in the body of the paper and on the required reference page per APA requirements and should not exceed 20%. Content from other sources that exceed 20% could indicate a lack of originality or possibly plagiarism and will be addressed following the Academic Integrity Policy noted below.
Third-party plagiarism software, such as Turnitin, may be used to assess the originality of a student's work in any assignment, papers, and quizzes, or exams to rule out plagiarism. NOTE: a link is provided in the course for students to submit a DRAFT Turnitin submission for a pre-review before submitting for grading to meet course and SU requirements.
The quality of the content will be assessed using the attached rubric. All criteria in the category must be met to earn the full points. See attached rubric.