Assignment Instructions

Prepare a revenue cycle plan for a community hospital. Include the following information in your plan:

Introduction
Evaluation of clinical data required for payment and reimbursement systems (PPS, DRG, RBRVS, RUGs, VBP, Billing/insurance plans).
Explanation of chargemaster and claims management applications and processes.
Assess the effect on healthcare finance of revenue management (cost reporting, budget variances).
Summarize revenue cycle management and reporting processes (CCI, X12N).
Evaluation of the severity of illness and how it impacts the healthcare payment systems.
The format of this plan is like a policy and procedure but is a longer document. Compile your document based on the findings and collection of information for each of the requirements.

Domain IV. Revenue Cycle Management

IV.3. Evaluate compliance with regulatory requirements and reimbursement methodologies.

Introduction

A community hospital’s revenue cycle management plan is critical to ensuring that the hospital is able to financially sustain its operations and provide high-quality care to its patients. This plan outlines the processes and systems that the hospital will use to manage its revenue and ensure compliance with regulatory requirements and reimbursement methodologies.

Evaluation of clinical data required for payment and reimbursement systems

To effectively manage its revenue, a community hospital must have a thorough understanding of the various payment and reimbursement systems that it will be required to comply with. These systems include the Prospective Payment System (PPS), Diagn-Related Groups (DRGs), Resource-Based Relative Value Scale (RBRVS), Resident Assessment Instrument for Long-term Care (RAI/MDS), Value-Based Purchasing (VBP), and Billing/Insurance plans. Each of these systems has its own unique set of requirements and reimbursement rates, and the hospital must ensure that it is collecting and reporting the necessary clinical data to comply with these systems.

Explanation of chargemaster and claims management applications and processes

The chargemaster is a hospital’s master list of charges for all services and procedures provided. It is used to ensure that the hospital is accurately billing for services and to identify areas where the hospital may be able to increase its revenue. The claims management process involves submitting claims to insurance companies and other payers for reimbursement. This process includes verifying patient eligibility, collecting patient financial information, and ensuring that the claims are being submitted in a timely and accurate manner.

Assess the effect on healthcare finance of revenue management

Effective revenue management can have a significant impact on the financial health of a community

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