A third-party payer manages healthcare expenses for the insured (patient) and other covered parties and provides reimbursement for treatment and services covered under a contractual agreement between the insured and the payer.
A third-party payer manages healthcare expenses for the insured (patient) and other covered parties and provides reimbursement for treatment and services covered under a contractual agreement between the insured and the payer. Several examples of third-party payers include HMOs, PPOs, Medicare, and Workers’ Compensation. Select two of the third-party payers to compare and contrast based on your readings.
Consider in your discussion the differences and similarities in access to providers, choice of provider, out-of-pocket costs to the patient such as required co-pays and coinsurance and deductibles, and appeals for denied services. Identify based on your comparisons which type of plan you would prefer as a patient and why.
In your reply post, comment on at least one of your classmates’ discussion and choice of plan and how it compares to your choice.
HIM2133 Revenue Cycle and Billing
Module 3 Discussion
Electronic Claims Processing
Heritage Medical Center is converting to electronic claims processes after years of using paper forms. Compare and contrast the PHI privacy and security concerns that may result from the use of an electronic claims submission process to those that are likely to occur with paper claims. Include a minimum of one potential privacy concern as well as one concern related to security.
Additional Notes:
The discussion is to focus on the concerns relative to the claims processing procedures. What will change with the electronic processing of claims that is different from processing paper claims?
Specify in your narrative when you are addressing privacy concerns vs the security concerns to provide clarification to the reader.
Include a minimum of one Privacy concern and one Security concern.
Provide APA in-text citations and references for the sources you utilize in preparing your response.
In your reply posts, respond to at least one other student’s discussion post indicating whether or not you agree with the concerns they have identified and state your reasons for agreement or disagreement.
HIM2133 Revenue Cycle and Billing
Module 4 Discussion
Error-Proofing the Chargemaster Process
Read the article Charging vs Coding (Pilato, 2013). Choose one area of disconnect mentioned in the article and describe the issue along with a suggestion for error-proofing the process. Indicate why the error-proofing method would be effective in the area of disconnect chosen.
In your follow-up posts, respond to one student’s post. Comment on their suggestion for error-proofing the process, and offer other suggestions.
Reference
Pilato, Jeff, MHA,R.T.R., C.P.C.-H. (2013). Charging vs. coding. Journal of AHIMA, 84(2), 58-61. Retrieved from https://search.proquest.com/docview/1282108260?accountid=40836
HIM2133 Revenue Cycle and Billing
Module 5 Discussion
NCCI Edits and Medically Unlikely Edits
The National Correct Coding Initiative (NCCI), also known as CCI, was established to promote correct coding and avoid inappropriate payment to providers. Review the article How to use the NCCI Tools. Based on your course readings and review of the NCCI Tool, explain what you think the impact would be on payment to the provider if these edits weren’t used.
In your reply post, comment on one other student’s idea of the impact on payments to the provider as it compares to yours.
HIM2133 Revenue Cycle and Billing
Module 6 Discussion
Revenue Cycle Performance Benchmarks
The Healthcare Financial Management Association (HFMA) has identified a number of key revenue cycle performance measures. Several of the measures are listed below. Choose three of the following performance measures/benchmarks identified by the HFMA. Based on your readings, indicate how improvement in the benchmark enhances revenue cycle performance (for example, improved cash flow, improved turnaround on billing, or increased collections). More than one benefit might be applicable to each benchmark. Your post should demonstrate how improvements in these metrics relate to the overall goals of the revenue cycle. (Reference earlier chapter readings and Lesson Content regarding revenue cycle performance improvement considerations.)
Decreased days in accounts receivable
Coder productivity
Reduction of encounters that are Discharged, No Final Bill (DNFB)
Decrease in Wrong Medical Record Number Assignments
Decreased turnaround on discharge deficiency analysis (missing documentation)
Implementation of point-of-service collections
Decreased rejections or denials
You can do this in either a written narrative, data table or a power point format. Organize your information so that it is reader friendly and makes the information clear.
Example:
Performance Measurement
Specify How Improvement Enhances Revenue Cycle Performance
Impact on Overall Revenue Cycle Goals
HIM/Record Management (NOTE-choose 3 measurements from the above list. Do not use this measurement in your post-example only)
-Accuracy of records supports optimization of revenue
-Access to records supports timely billing
Data Quality
Reduction in denials
Improved revenue turnaround
If you use external sources to help you formulate your discussion post, be sure to include citations for those sources.
In your follow-up post, reply to at least one other student. Comment on the benchmarks that the student selected and indicate what you have learned from his or her analysis of the performance metrics.
HIM2133 Revenue Cycle and Billing
Module 1 Assignment
Revenue Cycle Workflow Scenarios
Inherent in the Revenue Cycle workflows is the need to collaborate with other departments to ensure performance benchmarks are met and the ultimate goal of timely and accurate cash flow is attained. In this activity, you will identify which departments (2 or more departments) need to work together to resolve the situation presented in several scenarios.
To complete this assignment, do the following:
Download the scenarios below.
Revenue Cycle Workflow Scenarios
Beneath each scenario on the downloaded “Revenue Cycle Workflow Scenario worksheet”, identify the departments/team players working together to resolve the issue stated in the scenario. Access the list of Revenue Cycle Departments/Services with the Description of Activities via the Module 1 Lesson Content “Common Revenue Cycle Activities” page.
Thoroughly explain each department/team player’s role or action involved in resolving the stated issue in the scenario.
Identify a minimum of two (2) departments or team players involved in the problem resolution.
Revenue Cycle Workflow Resources
HIM2133 Revenue Cycle “Big Picture Relationships
WebEx Recordings
Streaming Link:
https://rasmussen.webex.com/rasmussen/ldr.php?RCID=b68fcfc7e6b5ea41321eed682e5e961c
Download Link:
https://rasmussen.webex.com/rasmussen/lsr.php?RCID=e582320c44af50a668b77d680b82a7b5
If you need assistance with using Microsoft Word, please visit the Video Tutorials page in the Course Materials folder.
HIM2133 Revenue Cycle and Billing
Module 2 Assignment
Medicare and Medicaid Administration
The Centers for Medicare and Medicaid Services (CMS) has specific administrative rules that need to be followed in order for providers to bill and receive reimbursement for services. For this assignment, you will read three scenarios that demonstrate several key concepts of the Medicare and Medicaid programs and then answer questions pertaining to those scenarios.
To complete this assignment, do the following:
Download the scenarios in the document below:
Medicare and Medicaid Administration Scenarios
Type your responses to the questions beneath each scenario.
If you need assistance with using Microsoft Word, please visit the Video Tutorials page in the Course Materials folder.
Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.
Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:
HIM2133 Revenue Cycle and Billing
Module 2 Assignment
Data Reporting Analysis
Data collection is an important aspect of the revenue cycle functions. Collection begins with the recording of patient demographic and insurance information at the point of registration. It then continues throughout the revenue cycle workflow with the capture of treatment information, charges, diagnostic and procedural codes, claims data, and information resulting from payments and denials. The data is housed in various databases, some that are standalone and others that are integrated. These databases can be accessed by authorized personnel to obtain the data needed in the performance of the healthcare facility’s planning, operations, and reporting requirements.
You work as a Coding Manager at a hospital. The hospital is considering building an Ambulatory Surgery facility for orthopedic and general surgery procedures, and several providers are interested in moving their practices and surgical interventions to this new location. In preparation for the Request for Proposal (RFP), the executive team is in need of clinical data. The HIM Director has been contacted and asked to pull statistical data.
At the HIM Director’s request, you have created a report of the top 5 diagnoses/procedures that shows total charges, total reimbursement, and quarterly patient volumes. In addition to the report, the HIM Director would like for you to analyze the data.
To complete this assignment, first download a copy of the report. Then, in a separate Word document, type your responses to the questions below:
Which of the diagnoses/procedures would be the highest revenue generating?
Which of the diagnoses/procedures may be considered for exclusion from the initiative based on volumes or revenue-and why?
Which of the diagnoses/procedures has a high volume, but lowest revenue?
Which of the diagnoses/procedures would benefit the most with a shift in payer mix (increase or decrease in patient volumes by payer)? Which payer and what type of change in volumes?
Note: Payer mix is the proportion of reimbursement that is generated from the different payers within a subset. In this example, there are 3 payers contributing to the total reimbursement for the 5 different subsets of procedures performed.
Which of the diagnoses/procedures would benefit the most from increased patient volumes?
HIM2133 Revenue Cycle and Billing
Module 3 Assignment
Prepare Insurance Claims for Submission
This assignment will provide you with insight into the use of data as it flows throughout the revenue cycle. Information gathered at the time of registration (demographics, insurance information, and admission date), charge capture throughout treatment and provision of services, the application of ICD-10, CPT, and HCPCs codes as well as provider information culminates in the claim form that is finalized and submitted for payment.
In this assignment, you will prepare two CMS-1500 and two UB-04 insurance claim forms using the data in four case scenarios.
To complete this assignment, do the following:
Download the zip file containing the four case scenarios below.
Case Scenarios
Download the CMS-1500 and UB-04 forms below.
CMS-1500 Form
UB-04 Form
Save two copies of each form on your computer (one for each of the two CMS-1500 scenarios and one for each of the two UB-04 scenarios). Save each form with a unique file name. Include the Case ID and form type in the file name (for example, CMS15001a, CMS15001b, UB2a, UB2b).
Download the instructions for completing the CMS-1500 and UB-04 forms below.
Instructions for Completing the CMS-1500 and UB-04 Forms
Using Adobe Acrobat Reader, enter the information from the case scenario into the appropriate field on the corresponding form. Refer to your readings for Physician and Hospital Medical Billing for information on CMS-1500 and UB-04 form locators and required information.
(If you do not have Adobe Acrobat Reader, download it from the Adobe website.)
For the CMS-1500 forms: Enter your name and date in the box in the upper left of the form. Enter the Case ID in the box in the upper right. Complete all pertinent fields #1-11d and 14-33 according to the data in the case and the guidelines you downloaded in Step 4.
For the UB-04 forms: Enter your name, the date, and the Case ID in the “Responsible Party” field (field 38) on the form. Complete all pertinent fields according to the data in the case and the guidelines you downloaded in Step 4.
HIM2133 Revenue Cycle and Billing
Module 4 Assignment
Appeals Process
Despite the efforts to submit claims that are “clean,” denials, rejections, and partial payments will occur. When a facility receives a denial, rejection, or partial payment, a determination will need to be made regarding the action to be taken by the facility (accept the denial, rejection, or partial payment, resubmit the claim, or appeal).
To complete this assignment, do the following:
Download the table you will use for this assignment below.
Appeals Process assignment
For each reason in the table you downloaded, indicate the appropriate action (accept the denial, rejection, or partial payment, resubmit the claim, or appeal) and provide the rationale for your decision.
HIM2133 Revenue Cycle and Billing
Module 5 Assignment
Posting a Payment
When a patient or the insurance carrier makes a payment on a patient’s account, the data reflecting this payment must be entered into the organization’s accounting system. The Remittance Advice forms that contain this data are not standardized; therefore, they will look different from payer to payer and use the payer’s preferred descriptors. In this assignment, you will use an Excel spreadsheet to capture patients’ Remittance Advice information.
To complete this assignment, do the following:
Download the Remittance Advice document below. This document contains Remittance Advice information for the patients you will be working with for this assignment.
Remittance Advice Information
Download the Excel spreadsheet below. This spreadsheet contains a sample posting for you to use as a guide.
Payment Posting Spreadsheet
Beneath the yellow sample row in the spreadsheet, record the payments received for each patient contained in the Remittance Advice Information document. Use the following guidelines in capturing the data:
Payments received for individually charged items also need to be posted.
If needed, calculate the total amount reimbursed based on payment information provided.
Record the date the payment was received (Payment Date) in the format MM/DD/YY.
Record the Medical Record Number (MRN) and account/encounter number (Acct#) without leading alpha characters or dashes.
Format payment amounts as currency, in whole numbers and using the dollar ($) sign (for example, $10 or $1,000).
Record payment method as one of the following: Cash, Personal Check, Insurance Payment.
Any payments made by the patient themselves, need to be recorded as a separate line item, the same as if it was separate insurance
HIM2133 Revenue Cycle and Billing
Module 6 Assignment
Revenue Cycle Job Research
For this assignment, you will be researching potential career roles in the healthcare revenue cycle field, which your health information education prepares you for.
To complete this assignment, do the following:
Research positions in the revenue cycle using your course readings, the AHIMA Career Map (http://hicareers.com/CareerMap/), or other resources you may find on the Internet. From this research, select three different positions that interest you. Identify the job title and provide a brief overview of the responsibilities and which component of the revenue cycle you think this position belongs in.
Select one revenue cycle position from a career job site where open positions are listed, such as Indeed.com, Simply Hired, or AHIMA Career Assist (http://ahima.org). (On the AHIMA home page, click Career & Student Center, and then click Career Assist: Job Bank).
Prepare a short narrative describing the one position you selected in #2 above. The narrative summary of your research should include the following:
Job title
Overview of the role and responsibilities
Job requirements: education, experience, certifications, and other skills
Whether this is a remote work opportunity or requires travel or relocation
Salary range, if available
Number of direct reports, if applicable
Site(s) responsibility
Type of organization (for example, acute care, vendor or contract service, ambulatory care, physician clinic, academic institution)
In your narrative, comment on why you chose this position, what you found interesting about the role, and how and where it fits in the revenue cycle.
Include an APA-formatted References page of all the sources you accessed and used in your narrative, including job search sites. Be sure to cite all sources within your narrative.
For more information about formatting a References page, see the Rasmussen APA Guide.
The narrative summary should be single spaced, well organized, and presented in a professional manner free of grammatical or spelling errors. The summary should range between 100 and 150 words and include all of the required elements listed above.
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