Healthcare Reimbursement (HCM345)

n your post, evaluate the legal and ethical practices to prevent fraud and abuse. How does fraud and abuse impact the costs of healthcare? What types of policies and procedures should be in place to prevent fraud and abuse?

what ARE SOME changes in healthcare regulations 

why does the insurance company pay the provider more than necessary? 

provide an in-depth analysis that demonstrates a good understanding of challenges of healthcare reimbursement concepts

In your post, evaluate the purpose of recovery audit contractors (RACs) and electronic health records (EHRs), as well as the impact on either case management or performance incentives. Support your answer with course resources.

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.

In Milestone Two, you will begin thinking about reimbursement in terms of billing and marketing. Reimbursement is a complex process with several stakeholders; this milestone allows you to begin thinking about the key players, including third-party billing, data collection, staff management, and ensuring compliance. Marketing and communication also plays a vital role in reimbursement; this milestone offers a chance to begin analyzing effective strategies and their impact.Submit your draft of Sections III and IV of the final project. Specifically, the following critical elements must be addressed:

1. Billing and Reimbursement
   • 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. How do third party policies impact the payer mix for maximum reimbursement?
   • 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.
   • Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
   • 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.
2. Marketing and Reimbursement
   1. Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete evidence
      or research.
   2. Discuss the resources needed to ensure billing and coding compliance with regulations.
   3. Evaluate strategies to ensure stakeholders involved in the reimbursement process adhere to ethical standards