Recommend a method for determining a pricing structure.

Revenue and Reimbursement

Write a 3–4-page proposal for billing changes, and explain how the proposed changes will benefit the organization, the physicians, and the patients.

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Note: The assessments in this course build upon each other, so you are strongly encouraged to complete them in sequence.

Resources for Further Exploration

You may use the following optional resources to further explore topics related to competencies.

Coding and Reimbursement

This website focuses on medical billing and revenue cycle management, and it has helpful links to education and publications on these topics.

  • Healthcare Billing and Management Association. (n.d.). Retrieved from https://www.hbma.org/.

The information on this website relates to the billing and coding process, and it provides links and information on revenue and reimbursement cycles for health care organizations.

  • American Academy of Professional Coders. (n.d.). Medical billing and coding. Retrieved from https://www.aapc.com/medical-billing/medical-billing-and-coding.aspx

This website provides an overview of each code set in relation to HIPAA.

  • Centers for Medicare & Medicaid Services. (n.d.). Code sets overview. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets/index.html

This website provides technical process information on aspects of ICD-10 codes, guidelines, and regulations.

  • Centers for Medicare & Medicaid Services. (n.d.). ICD-10. Retrieved from https://www.cms.gov/Medicare/Coding/ICD10/index?redirect=/icd10

Financial Strategies

This is a bi-weekly newsletter focusing on health care finance strategies for a variety of topics. The main website contains links to publications and resources.

  • Healthcare Financial Management Association. (n.d.). Healthcare finance strategies. Retrieved from http://www.hfma.org/Content.aspx?id=1728

Financial Management

This web page discusses electronic exchanges between administrative and financial entities, and it contains helpful links.

  • Centers for Medicare & Medicaid Services. (n.d.). Transactions overview. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Transactions/TransactionsOverview h

 

ASSESSMENT INSTRUCTIONS

PREPARATION

Use the Capella University Library and the Internet to locate resources and information on health care revenue cycles and billing processes.

Imagine that you have just stepped into a new role as the office manager for a very successful clinic. The clinic is a conglomeration of physicians who offer specialized care. Each group of physicians tried to manage their own billing process but it quickly became obvious that one billing office would be more efficient. You realize that there has been a lack of consistency in the clinic and that you will need to update the billing policies and procedures immediately. You also realize that there is always resistance to change, and you will need to provide evidence supporting the changes you plan to make.

Prepare a proposal for billing changes that you would present to the physicians. You will need to support each proposed change with relevant evidence to assure buy-in from the physicians.

There is no specific format you must follow for this assessment, but be sure that your proposal is clear, logical, and succinct. Follow APA guidelines for any in-text citations and references. Include a title page and reference page.

REQUIREMENTS

Write a proposal for changes you would like to make to the billing policies and procedures in a successful physicians clinic. Include the following in your proposal:

  • Develop a step-by-step process for the entire revenue cycle from pre-verification of insurance to accounts receivable management.
  • Recommend a method for determining a pricing structure. What factors can influence pricing?
  • Explain the factors that must be considered while negotiating insurance contracts. What major payer categories are appropriate for this practice?
  • Explain how the clinic will handle private pay and charity care.
  • Recommend either an installed or a web-based billing software system. (Please note that you should not recommend a specific brand of software; just the type of software.)
  • Explain how the changes will benefit the physicians, the clinic, and patients.

ADDITIONAL REQUIREMENTS

  • Include a title page and reference page.
  • Number of pages: 3–4.
  • At least three current scholarly or professional resources.
  • APA format for in-text citations and references.
  • Times New Roman font, 12 point.
  • Double-spaced.

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