Need milestone complete by Sunday at 2pm
IHP 630 Milestone Three Guidelines and Rubric
Overview: Hospital administrators review accounts receivable schedules and reports to determine how much revenue is being received from various sources
(i.e., Medicaid, Medicare, Anthem, self-pay from patients, and other third-party payers). Revenue from various sources is referred to as the organization’s “payer
mix.” In this milestone, you will examine operational and strategic planning in healthcare and consider selecting the three elements that you feel will be most
important to complete in terms of receiving feedback.
Prompt: Submit a draft of the Third-Party Payment Systems and the Operational and Strategic Planning in Healthcare portions of your research and analysis.
Specifically, the following critical elements must be addressed:
IV. Third-Party Payment Systems:
a) Healthcare System Reimbursement: Evaluate third-party payer models for the impacts they present on healthcare system reimbursement.
b) Reporting Requirements: Analyze the reporting guidelines of third-party payer payment systems. What opportunities and challenges do they
present for healthcare leaders in meeting reporting requirements?
c) Compliance Standards and Financial Principles: Analyze how healthcare organizations in general utilize financial principles to guide strategic
planning to ensure the meeting of third-party submission requirements.
d) Reimbursement Methods: Considering third-party payer systems, what strategies would you recommend organizations implement in order to
receive full reimbursement on claims as well as to improve timeliness of this reimbursement? Be sure to justify your recommendations.
V. Operational and Strategic Planning in Healthcare:
a) Pay-For-Performance Incentives: Based on your prior analysis of the impact of case rates and management utilization data on pay-for-
performance incentives, recommend appropriate operational strategies to improve performance measures that will maximize reimbursement.
Be sure to provide support for your recommendations.
b) Operational Performance Measures: Considering benchmarking data, recommend performance measures that should be monitored for the
purpose of maximizing reimbursement.
c) Teamwork and Strategic Planning: Recommend collaborative teamwork principles that would be beneficial for healthcare strategic planning in
terms of reimbursement. Be sure to provide support for your recommendations.
d) Communicating Strategic Planning Across Teams: What types of tools or strategies would you recommend for communicating strategic planning
conclusions to key stakeholders, members of cross-disciplinary teams, and the rest of the organization? In other words, how would you
communicate strategic planning information to clinical vs. non-clinical staff? To administrative staff? Be sure to provide support for your
recommendations.
e) Financial and Reimbursement Strategies: Considering cash flow and days in accounts receivable for hospital and health systems, recommend
reimbursement strategies that would be appropriate for low- and high-performing health systems. Provide evidence to support your conclusion.
Rubric
Guidelines for Submission: Your draft of the third-party payment systems and the operational and strategic planning in healthcare portions of your research and
analysis should be 2–3 pages in length and should be double-spaced in 12-point Times New Roman font with one-inch margins, in a single Microsoft Word
document. All citations and references should be formatted according to current APA guidelines. Include at least two references.
Critical Elements Proficient (100%) Needs Improvement (70%) Not Evident (0%) Value
Third-Party
Payment:
Reimbursement
Accurately evaluates third-party payer
models for the impact they present on
healthcare system reimbursement
Evaluates third-party payer models for
the impact they present on healthcare
system reimbursement but with gaps
in accuracy or detail
Does not evaluate third-party payer
models for the impact they present on
healthcare system reimbursement
10
Third-Party
Payment: Reporting
Requirements
Accurately analyzes reporting
guidelines required by third-party
payer payment systems for the
opportunities and challenges facing
healthcare leaders in meeting
reporting requirements
Analyzes reporting guidelines required
by third-party payer payment systems
for the opportunities and challenges
facing healthcare leaders in meeting
reporting requirements but with gaps
in accuracy or detail
Does not analyze reporting guidelines
required by third-party payer
payment systems for the
opportunities and challenges facing
healthcare leaders in meeting
reporting requirements
10
Third-Party
Payment:
Compliance
Standards
Accurately analyzes how healthcare
organizations utilize financial
principles for guiding strategic
planning in ensuring compliance with
third-party payer submission
requirements
Analyzes how healthcare
organizations utilize financial
principles for guiding strategic
planning in ensuring compliance with
third-party payer submission
requirements but with gaps in
accuracy or detail
Does not analyze how healthcare
organizations utilize financial
principles for guiding strategic
planning in ensuring compliance with
third-party payer submission
requirements
10
Third-Party
Payment:
Reimbursement
Methods
Recommends appropriate strategies
for organizations to receive full
reimbursement on claims and
improve timeliness of reimbursement
from third-party payer systems,
justifying recommendations
Recommends strategies, but they are
not appropriate for organizations to
receive full reimbursement on claims
and improve timeliness of
reimbursement from third-party
payer systems or response has gaps in
detail or relevant justification
Does not recommend strategies for
organizations to receive full
reimbursement on claims and
improve timeliness of reimbursement
from third-party payer systems
10
Planning: Pay-for-
Performance
Makes appropriate recommendations
for operational strategies to improve
performance measures that will
maximize reimbursement based on
prior analysis of impact of case rates
and management utilization data,
providing support for
recommendations
Makes recommendations, but they
are not appropriate for operational
strategies to improve performance
measures that will maximize
reimbursement, recommendations
are not based on prior analysis of
impact of case rates and management
utilization data, or response has gaps
in detail or relevant support
Does not make recommendations for
operational strategies to improve
performance measures that will
maximize reimbursement
10
Planning:
Operational
Performance
Recommends appropriate
performance measures that should be
monitored for the purpose of
maximizing reimbursement,
considering benchmarking data
Recommends performance measures
that should be monitored for the
purpose of maximizing
reimbursement, but measures are not
appropriate for the intended purpose
or recommendations are not based on
benchmarking data
Does not recommend performance
measures that should be monitored
for the purpose of maximizing
reimbursement, considering
benchmarking data
10
Planning: Teamwork Recommends appropriate
collaborative teamwork principles
that would be beneficial for
healthcare strategic planning in terms
of reimbursement, providing support
for recommendations
Recommends teamwork principles,
but they are not appropriate or
adequate for the intended purpose or
response has gaps in detail or relevant
support
Does not recommend collaborative
teamwork principles that would be
beneficial for healthcare strategic
planning in terms of reimbursement
10
Planning:
Communicating
Recommends appropriate tools or
strategies for communicating strategic
planning conclusions to various
audiences, providing support for
recommendations
Recommends tools or strategies, but
they are not appropriate for
communicating strategic planning
conclusions to various audiences or
response has gaps in detail or relevant
support
Does not recommend tools or
strategies for communicating strategic
planning conclusions to various
audiences
10
Planning: Financial
and Reimbursement
Strategies
Recommends appropriate
reimbursement strategies for low-
and high-performing health systems,
considering cash flow and days in
accounts receivable, supporting
conclusion with evidence
Recommends strategies for low- and
high-performing health systems, but
recommendations are not appropriate
for the intended purpose or do not
consider cash flow and days in
accounts receivable, or response has
gaps in detail or relevant support
Does not recommend reimbursement
strategies for low- and high-
performing health systems
10
Articulation of
Response
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
Submission has major errors related
to citations, grammar, spelling,
syntax, or organization that negatively
impact readability and articulation of
main ideas
Submission has critical errors related
to citations, grammar, spelling,
syntax, or organization that prevent
understanding of ideas
10
Total 100%
Title of Paper
6
Title of Paper
Student Name
SNHU
Title of Paper
Introduction
Anything you see in bold text will be deleted as you work on these sections of this paper. You will most likely write this section last, after you have completed all three milestones. This introduction serves as your introduction for the entire paper. Here, you will write no more than a page to identify the purpose of the paper (why you are writing this), the scope of the paper (a summary of what it covers), and the subject of your paper (the overarching topic).
Part 1: Financial Principles and Reimbursement
Reimbursement Strategies
This section of your paper is no more than half a page. You will use research to define case rates and management utilization. Then you will show how these factors impact pay for performance incentives. (Assume your reader knows what pay for performance is.)
Reimbursement Method
s
This section of your paper can easily be written as a chart. You will want to choose methods that are dissimilar enough to allow for comparison. Please use the chart I have provided for this section. (I know you are busy! I’m trying to make your life easier.) You need no further explanation other than the chart.
Reimbursement Method |
Advantages For Strategic Planning of Operational Performance |
Disadvantages For Strategic Planning of Operational Performance |
Best Use (Type of Facility and Why) |
Method 1 |
|||
Method 2 |
Financial Management Principle
s
Another Chart! You need no additional information other than what you include in the chart. You will include three of the financial management principles listed within the assignment directions (revenue reimbursement, benchmarking of industry standards, payer-mix breakdown of payers, case rate and utilization rate data) to identify how they are used to evaluate operational performance.
Financial Management Principle |
How It Is Used to Evaluate Operational Performance |
Accounts Receivable
This section is a half-page. You are addressing two main questions: What are at least two challenges associated with collecting payments for accounts receivable? And why must the healthcare organization monitor cash flow and days in accounts receivable?
Teamwork Principles
Another chart! I’m looking for four principles.
Teamwork Principle Used with Cross-Disciplinary Teams (Research best practices of Cross-Disciplinary Teams) |
A Challenge Presented By This Principle and Why |
Maximizing Reimbursement
This section is a half-page. Do healthcare organizations, in general, adequately utilize case rates and management utilization to maximize payment from payors?
Part 2: Federal and State Payment Systems
Federal and State Regulations
This section is no more than a half-page. Pick two recent federal or state regulations that present the most concern for healthcare leaders. Why do healthcare leaders need to be concerned about these regulations?
Reporting Requirements
This section is no longer than a page. Review CMS.gov. What are some items that are required to be reported for CMS? What are two opportunities (benefits for the healthcare organization and/or American health) and two challenges (concerns within the healthcare facility) for healthcare leaders in meeting the reporting requirements you described?
Compliance Standards
This section is no longer than a half-page. Return to your Financial Management Principles section on part one of this project. Look more closely at two of those principles and expand upon how those principles ensure compliance with CMS standards.
Government Payer Types
This section is no longer than a half-page. Identify two strategies you would recommend organizations implement to receive full and timely reimbursement on claims from CMS.
Part 3: Third-Party Payment Systems
Healthcare System Reimbursement
This section is no longer than a half-page. Choose a third party payor (Aetna, Blue Cross, Kaiser Permananete are all big ones). Identify two impacts a third party payor has on a healthcare organization. (Why should the healthcare organization care about meeting the requirements of the third party payor?)
Reporting Requirements
This section is no longer than a page. Using the same payor, what are some items that are required to be reported to that payor? What are two opportunities (benefits for the healthcare organization and/or American health) and two challenges (concerns within the healthcare facility) for healthcare leaders in meeting the reporting requirements you described?
Compliance Standards
This section is no longer than a half-page. Return to your Financial Management Principles section on part one of this project. Look more closely at two of those principles and expand upon how those principles ensure compliance with your third party payor standards.
Reimbursement Methods
This section is no longer than a half-page. Identify two strategies you would recommend organizations implement to receive full and timely reimbursement on claims from your third party payor.
Part 4: Operational and Strategic Planning in Healthcare
Pay-For-Performance Incentives
This section is no longer than a half-page. What are two operational recommendations you would make to improve performance measures so your organization can maximize reimbursement? Please explain how these two recommendation will help to improve performance measures.
Operational Performance Measures
This section is no longer than a half-page. What are two performance measures that should be benchmarked so reimbursement is maximized? Why?
Teamwork and Strategic Planning
Use the chart below for this section. Please select two techniques.
Collaborative Teamwork Technique |
How It Will Help Maximize Reimbursement |
Communicating Strategic Planning Across Teams
This section is no longer than a half-page. Identify and explain two methods you would use to communicate information to key stakeholders. For example, how would you communicate the same decision to patients, administrative staff, and clinicians?
Financial and Reimbursement Strategies
Use the chart below for this section.
++++++++++++ |
Cash Flow |
Days in Accounts Receivable |
|
Recommendation for Low Performing System |
What should the system do to improve cash flow? |
What should the system do to improve Days in A/R? |
|
Recommendation for High Performing System |
What should the system do to improve cash flow? |
References
Per APA requirements, references are written in alphabetical order. Only the first line of each reference is indented. See the course for more on how to write references in APA.
You will want to update this page with every milestone.