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HCM 345 Final Project Guidelines and Rubric
Overview
The final project for this course is the creation of a white paper.
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.
For your final project, you will assume the role of a supervisor within a PFS department and develop a white paper in which the necessary healthcare
reimbursement knowledge is outlined.
The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final
submissions. These milestones will be submitted in Modules Three and Five.
In this assignment, you will demonstrate your mastery of the following course outcomes:
HCM-345-01: Analyze the impacts of various healthcare departments and their interrelationships on the revenue cycle
HCM-345-02: Compare third-party payer policies through analysis of reimbursement guidelines for achieving timely and maximum reimbursements
HCM-345-03: Analyze organizational strategies for negotiating healthcare contracts with managed care organizations
HCM-345-04: Critique legal and ethical standards and policies in healthcare coding and billing for ensuring compliance with rules and regulations
HCM-345-05: Evaluate the use of reimbursement data for its purpose in case and utilization management and healthcare quality improvement as well
as its impact on pay for performance incentives
Prompt
You are now a supervisor within the patient financial services (PFS) department of a healthcare system. It has been assigned to you to write a white paper to
educate other department managers about reimbursement. This includes how each specific department impacts reimbursement for services, which in turn
impacts the healthcare organization as a whole. The healthcare system may include hospitals, clinics, , and more. For now, your boss has
asked you to develop a draft of this paper for the hospital personnel only; in the future, there may be the potential to expand this for other facilities.
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In order to complete the white paper, you will need to choose a hospital. You can choose one that you are familiar with or create an imaginary one. Hospitals
vary in size, location, and focus. Beckers Hospital Review has an excellent list of things to know about the hospital industry. Once you have determined the
hospital, you will need to think about the way a patient visit works at the hospital you chose so you can review the processes and departments involved. There
are several ways to accomplish this. Choose one of the following:
If you have been a patient in a hospital or if you know someone who has, you can use that experience as the basis for your responses.
Conduct research through articles or get information from professional organizations. Below is an example of how to begin framing your analysis.
A patient comes in through the emergency department. In this case, the patient would be triaged and seen in the emergency department. Think about what
happens in an emergency area. The patient could be asked to change into a hospital gown (think about the costs of the gown and other supplies provided). If the
patient is displaying signs of vomiting, plastic bags will be provided and possibly antinausea medication. Lab work and possibly x-rays would be done. The patient
could be sent to surgery, sent home, or admitted as an inpatient. If he or she is admitted as an inpatient, meals will be provided and more tests will be ordered
by the physicianagain, more costs and charges for the patient bill. Throughout the course, you will be gathering additional information through your readings
and supplemental materials to help you write your white paper.
When drafting this white paper, bear in mind that portions of your audience may have no healthcare reimbursement experience, while others may have been
given only a brief overview of reimbursement. The goal of this guide is to provide your readers with a thorough understanding of the importance of their
departments and thus their impact on reimbursement. Be respectful of individual positions and give equal consideration to patient care and the business aspects
of healthcare. Consider written communication skills, visual aids, and the feasibility to translate this written guide into verbal training.
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 these 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-forperformance incentives be measured?
B. Assess the activities within each department at this 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 departments impact on
reimbursement in a healthcare organization?
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III. Billing and Reimbursement
A. Analyze the collection of data by patient access personnel and its importance to the billing and collection process. Be sure to address the
importance of exceptional customer service.
B. Analyze how third-party policies would be used when developing billing guidelines for patient financial services (PFS) personnel and
administration when determining the payer mix for maximum reimbursement.
C. Organize the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain your
rationale on the order.
D. Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
E. Develop a plan for periodic review of procedures to ensure compliance. Include explicit steps for this plan and the feasibility of enacting this plan
within this organization.
IV. Marketing and Reimbursement
A. Analyze the strategies used to negotiate new . Support your analysis with research.
B. Communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts. Be sure to
include the different individuals within the healthcare organization.
C. Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete
evidence or research.
D. Discuss the resources needed to ensure billing and coding compliance with regulations and ethical standards. What would happen if these
resources were not obtained? Describe the consequences of noncompliance with regulations and ethical standards.
Milestones
Milestone One: Draft of Reimbursement and the Revenue Cycle
In Module Three, you will submit a draft of Sections I and II of the final project (Reimbursement and the Revenue Cycle, and Departmental Impact on
Reimbursement). This milestone will be graded with the Milestone One Rubric.
Milestone Two: Draft of Billing, Marketing, and Reimbursement
In Module Five, you will submit a draft of Sections III and IV of the final project (Billing and Reimbursement, and Marketing and Reimbursement). This milestone
will be graded with the Milestone Two Rubric.
Final Project Submission: White Paper
In Module Seven, you will submit your entire white paper. It should be a complete, polished artifact containing all of the critical elements of the final product. It
should reflect the incorporation of feedback gained throughout the course. This submission will be graded using the Final Project Rubric.
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Deliverables
Milestone Deliverable Module Due Grading
One Draft of Reimbursement and the Revenue
Cycle
Three Graded separately; Milestone One Rubric
Two Draft of Billing, Marketing, and
Reimbursement
Five Graded separately; Milestone Two Rubric
Final Project Submission: White Paper Seven Graded separately; Final Project Rubric
Final Project Rubric
Guidelines for Submission: This white paper should include a table of contents and sections that can be easily separated for each department area. It should be
a minimum of eight pages (in addition to the title page and references). The document should use 12-point Times New Roman font, double spacing, and oneinch margins. Citations should be formatted according to APA style.
Critical Elements Exemplary Proficient Needs Improvement Not Evident Value
Reimbursement
and the Revenue
Cycle:
Reimbursement
Meets Proficient criteria and
includes any unique attributes
of this specific organization
(100%)
Comprehensively describes
what reimbursement means to
a healthcare organization (85%)
Describes what reimbursement
means to a healthcare
organization, but description is
not comprehensive or is not
specific (55%)
Does not describe what
reimbursement means to a
healthcare organization (0%)
6.75
Reimbursement
and the Revenue
Cycle: Flow of the
Patient
Accurately illustrates the flow of
the patient through the revenue
cycle (100%)
Illustrates the flow of the
patient through the revenue
cycle, but illustration is unclear
or inaccurate (55%)
Does not illustrate the flow of
the patient through the
revenue cycle (0%)
6.75
Departmental
Impact on
Reimbursement:
Departments
Meets Proficient criteria and
communicates the impact in a
style that adheres to authentic
formatting for the business of
healthcare (100%)
Comprehensively describes the
impact of the departments that
utilize reimbursement data and
also influence reimbursement at
a healthcare organization (85%)
Describes the impact of the
departments that influence
reimbursement, but description
is not comprehensive or is not
specific to a healthcare
organization or to departments
that utilize reimbursement data
(55%)
Does not describe the impact
of the departments at a
healthcare organization that
influence reimbursement
(0%)
6.75
Departmental
Impact on
Reimbursement:
Activities
Meets Proficient criteria, and
assessment demonstrates keen
insight into the relationship
between departmental
activities and healthcare
reimbursement (100%)
Assesses the activities within
each department at a
healthcare organization for
how they may impact
reimbursement (85%)
Assesses the activities within
each department at a
healthcare organization but
does not explicitly link these
activities to reimbursement, or
assessment is not specific (55%)
Does not assess the activities
within each department at a
healthcare organization for
how they may impact
reimbursement (0%)
6.75
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Critical Elements Exemplary Proficient Needs Improvement Not Evident Value
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 (100%)
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 (55%)
Does not identify the
department responsible for
ensuring compliance of billing
and coding policies (0%)
6.75
Billing and
Reimbursement: Data
Meets Proficient criteria, and
analysis demonstrates a
nuanced insight into the
relationship between patient
access personnels collection of
data and the billing and
collection process (100%)
Analyzes the collection of data
by patient access personnel and
its importance to the billing and
collection process, including the
importance of exceptional
customer service (85%)
Analyzes the collection of data
by patient access personnel and
its importance to the billing and
collection process but does not
include the importance of
exceptional customer service
(55%)
Does not analyze the
collection of data by patient
access personnel (0%)
6.75
Billing and
Reimbursement:
Third-Party Policies
Meets Proficient criteria,
and analysis demonstrates a
keen insight into the
relationships between thirdparty policies, billing
guidelines, and payer mix
(100%)
Analyzes how third-party
policies would be used when
developing billing guidelines
for PFS personnel and
administration when
determining the payer mix for
maximum reimbursement
(85%)
Analyzes how third-party
policies would be used but
does not apply analysis toward
the development of billing
guidelines for PFS personnel
and administration or toward
the determination of the payer
mix for maximum
reimbursement (55%)
Does not analyze how thirdparty policies would be used
(0%)
6.75
Billing and
Reimbursement: Key
Areas of Review
Meets Proficient criteria, and
explanation of key areas of
review demonstrates a
nuanced insight into
reimbursement from thirdparty payers (100%)
Organizes and explains the
key areas of review in order
of importance for timeliness
and maximization of
reimbursement from thirdparty payers (85%)
Organizes and explains the
key areas of review in order of
importance for timeliness and
maximization of
reimbursement from thirdparty payers, but explanation
is cursory or illogical (55%)
Does not organize and
explain the key areas of
review in order of
importance for timeliness
and maximization of
reimbursement from thirdparty payers (0%)
6.75
Billing and
Reimbursement:
Structure
Meets Proficient criteria and
demonstrates creativity in the
structure identified (100%)
Describes a way to structure
follow-up staff in terms of
effectiveness and explains
rationale for effectiveness (85%)
Describes a way to structure
follow-up staff in terms of
effectiveness but does not
explain rationale for
effectiveness (55%)
Does not describe a way to
structure follow-up staff in
terms of effectiveness (0%)
6.75
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Critical Elements Exemplary Proficient Needs Improvement Not Evident Value
Billing and
Reimbursement: Plan
Meets Proficient criteria and
demonstrates ingenuity in the
review process (100%)
Develops a plan for periodic
review of procedures to ensure
compliance, including explicit
steps and the feasibility of
enacting the plan (85%)
Develops a plan for periodic
review of procedures to ensure
compliance but does not
include explicit steps or does
not include the feasibility of
enacting the plan (55%)
Does not develop a plan for
periodic review of procedures
to ensure compliance (0%)
6.75
Marketing and
Reimbursement:
Strategies
Meets Proficient criteria, and
research includes specific
examples applicable to
negotiation strategies (100%)
Analyzes the strategies used
to negotiate new managed
care contracts, supporting
analysis with research (85%)
Analyzes the strategies used to
negotiate new managed care
contracts but does not support
analysis with research (55%)
Does not analyze the
strategies used to negotiate
new managed care contracts
(0%)
6.75
Marketing and
Reimbursement:
Communicate
Meets Proficient criteria and
communicates this in a manner
that would be motivational for
the individual (100%)
Communicates the important
role that each individual within
this healthcare organization
plays with regard to managed
care contracts, including the
different types of individuals
within the organization (85%)
Communicates the important
role that each individual within
this healthcare organization
plays with regard to managed
care contracts but does not
include the different types of
individuals within the
organization (55%)
Does not communicate the
important role that each
individual within this
healthcare organization plays
with regard to managed care
contracts (0%)
6.75
Marketing and
Reimbursement:
Contracts
Meets Proficient criteria and
includes enough information to
make informed decisions on
accepting the contract (100%)
Explains how new managed
care contracts impact
reimbursement for the
healthcare organization,
including support for
explanation with concrete
evidence or research (85%)
Explains how new managed
care contracts impact
reimbursement for the
healthcare organization but
does not include support for
explanation with concrete
evidence or research (55%)
Does not explain how new
managed care contracts
impact reimbursement for
the healthcare organization
(0%)
6.75
Marketing and
Reimbursement:
Compliance
Meets Proficient criteria and
includes details such as how
often the resources should be
updated to stay current with
regulations (100%)
Comprehensively discusses the
resources needed to ensure
billing and coding compliance
with regulations and ethical
standards (85%)
Discusses the resources needed
to ensure billing and coding
compliance with regulations
and ethical standards, but
discussion is not comprehensive
(55%)
Does not discuss the
resources needed to ensure
billing and coding compliance
(0%)
6.75
Articulation of
Response
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented in
a professional and easy to read
format (100%)
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
(85%)
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact
readability and articulation of
main ideas (55%)
Submission has critical errors
related to citations, grammar,
spelling, syntax, or
organization that prevent
understanding of ideas (0%)
5.5
Total 100%
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