Milestone

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%