Posted: August 2nd, 2022

reim1

Develop a two-page memo to help relevant stakeholders at Vila Health’s St. Anthony Medical Center better understand traditional and emerging reimbursement models.

Introduction

Note: This assessment uses the following media as the context for developing the reimbursement model memo. Review this media before you submit your assessment.

·

Vila Health: Investigating a Readmission

.

Basic understanding of the reimbursement system requires one to appreciate the size and scope of the system, the complexities associated with the system, and the various subsystems and payment rules associated with health care reimbursement and finance. As a dominant player in the health care sector, the U.S. federal government is the largest single payer for health care services. As a result of its size and dominance within the system, any changes made by the federal government regarding its reimbursement of health services profoundly affect those who are rendering the care, including providers, other payers, and the health system overall. In addition to government-sponsored health insurance, various other forms of health coverage, generally tied to employment as a benefit, were introduced in the United States to help offset the expenses associated with the treatment of illness and injury.

In an effort to address concerns within the U.S. health system regarding cost, access, and quality, Congress passed the Patient Protection and Affordable Care Act (PPACA or ACA) in 2010, with President Barack Obama signing it into law. Components of the PPACA included making health insurance coverage affordable, expanding Medicaid coverage, and improving quality while controlling costs. To this end, the ACA required the Centers for Medicare & Medicaid (CMS)to promote the concept of the accountable care organization (ACO) through a shared savings plan driven by a triple-aim approach. In addition to the ACO, the ACA required CMS to implement value-based purchasing programs that would reward hospitals for the quality of care they provided to enrollees.

As the recipient of the largest share of Medicare funds, the new value-based purchasing approach measures hospital performance using four domains:

1. Clinical care.

2. Safety.

3. Efficiency and cost reduction. 

4. Patient experience of care (Casto & Forrestal, 2019, p. 274).

Each measure scores the hospital performance achievement as well as their performance improvement.

As a health care sector employee, understanding the complex U.S. health care reimbursement system allows one to serve as a reference to internal and external stakeholders, family members, and organizational departments whose needs often require a working knowledge of how the system is financed. 

In this assessment, you demonstrate your understanding of traditional and emerging health care reimbursement models by composing a memo that outlines the characteristics and differences between reimbursement models. This memo targets relevant stakeholders from the Vila Health media simulation based in St. Anthony Medical Center.

Reference

Casto, A. B. (2019). Principles of healthcare reimbursement (6th ed.). AHIMA Press.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Compare current trends and traditional methods of payment in the health care industry.

. Describe traditional payment models in health care.

. Describe current trends in health care payment models.

· Competency 2: Assess health care reimbursement.

. Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.

. Explain reasoning for newer models of reimbursement in health care.

. Explain quality concerns affecting reimbursement given a specific patient scenario.

· Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.

. Adhere to the rules of grammar, usage, and mechanics.

. Apply APA formatting to in-text citations and references.

Instructions

You will use 
Vila Health: Investigating a Readmission
 as the context to address Part 4 of this assessment.

Several of the Vila Health’s stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. For this assessment, prepare a two-page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.

Support your assertions in the memo with at least three academic sources. This may require you to do additional independent research. You may wish to consult the 

Health Care Administration Undergraduate Library Research Guide

 before you begin any additional research.

This assessment has four main parts.

Part 1: Traditional Payment Methods

Relevant scoring guide criteria:

· Describe traditional payment models in health care.

. “Describe” means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.

. Identify the traditional payment models.

. What are the key characteristics of these reimbursement models?

. How was quality monitored under these models?

· Adhere to the rules of grammar, usage, and mechanics.

. “Grammar” refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).

. “Usage” refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.

. “Mechanics” refers to correct use of capitalization, punctuation, and spelling.

· Apply APA formatting to in-text citations and references.

This part should be at least one paragraph long, but probably no more than half a page.

Part 2: Current Trends in Healthcare Payment

Relevant scoring guide criteria:

· Describe current trends in health care payment models.

. Identify the current trends in health care payment models.

. What are the key characteristics of these reimbursement models?

. How is quality monitored under these models?

· Explain reasoning for newer models of reimbursement in health care.

. “Explain” means to make (an idea, situation, or problem) clear to someone by describing it in more detail or revealing relevant facts or ideas.

· Adhere to the rules of grammar, usage, and mechanics.
· Apply APA formatting to in-text citations and references.
This part should be at least one paragraph long, but probably no more than half a page.

Part 3: Comparison of Models

Relevant scoring guide criteria:

· Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.

. Develop a concise comparison of the key similarities and differences of the reimbursement process between traditional and current models.

· Adhere to the rules of grammar, usage, and mechanics.
· Apply APA formatting to in-text citations and references.

This part should likely be between a half and one page long.

Part 4: Quality Concerns

Relevant scoring guide criteria:

· Explain quality concerns affecting reimbursement given a specific patient scenario.

. Specifically address the recent problematic patient case from the Vila Health: Investigating a Readmission scenario.

. Briefly discuss how the care provided would be reimbursed under prior models versus reimbursement under newer models, based on your assertions in Part 3 of your memo. 

. Also, identify quality issues that will likely impact the organization’s reimbursement under new payment models.

· Adhere to the rules of grammar, usage, and mechanics.
· Apply APA formatting to in-text citations and references.
This part should be at least one paragraph long, but probably no more than half a page.

Additional Submission Requirements

· Structure: Structure your submission like a memo, with an additional, APA-style references page. Use the 

Reimbursement Model Memo template [DOC]

 provided. You may wish to refer to the following example when developing your memo:

.

Sample Memo

.

· Length: 2–3 pages, plus a references page.

· References: Cite at least three current scholarly or professional resources.

. Your textbook can be one of the three.

· Format: Use APA style for references and citations only. Refer to:

.

APA Style Paper Tutorial [DOCX]

.

. Additional APA resources located in the courseroom navigation panel.

· Font: Times New Roman, 12 point, double-spaced.

PAGE

MEMO

To:

From:

Date:

Subject: Reimbursement Models in Healthcare (BHA-FPX4009 -Assessment 1)

Introduction

[Provide a brief introduction (preview of the main theses of your paper) here and delete all statements within brackets, such as this paragraph, and replace with your discussion. Also, before you begin, review the “Scoring Guide” and understand the difference between “Distinguished,” “Proficient,” “Basic,” and “Non-Performance.” These “Scoring Guides” are used to grade the assignment. This is why each Template is set up with headings (below) that correspond with the “Scoring Guides” for this specific assignment. Please leave the Headings (below) in the paper.]

Traditional Payment Methods

[Explains traditional payment methods in health care, such as fee-for-service or capitated payment].

Current Trends in Health Care Payment

[Explains current trends in health care payment, such as value-based or accountable care organizations. Explains reasoning for newer models of reimbursement in health care and provide relevant examples].

Comparison of Models

[Compare and contrast how quality outcomes are rewarded under traditional and current payment methodologies in health care and provide relevant examples].

Quality Concerns

[Describe quality concern affecting reimbursement given a specific patient scenario].

Conclusion

[Summarize the main themes of your paper],

References

[Lastname, C. (2008). Title of the source without caps except Proper Nouns or: First word after colon. The Journal or Publication Italicized and Capped, Vol# italicized(Issue#), Page numbers.

Lastname, O. (2010). Online journal using DOI or digital object identifier. Main Online Journal Name, Vol# italicized(Issue#), 159–192. https://doi.org/10.1000/182

Lastname, W. (2009). If there is no DOI use the URL of the main website referenced. Article Without DOI Reference, Vol# italicized(Issue#), 166–212. http://www.mainwebsite.org

NOTE: The above references are SAMPLES ONLY. For more information and example related to references, visit Capella’s Writing Center. YOU ARE RESPONSIBLE FOR SUBMITTING APPROPRIATE IN-TEXT AND REFERENCE PAGE CITATIONS.]

7/31/22, 10:24 PM

Reimbursement Models Scoring Guide

https://courserooma.capella.edu/bbcswebdav/institution/BHA-FPX/BHA-FPX4009/210100/Scoring_Guides/a01_scoring_guide.html 1/1

Reimbursement Models Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

Describe traditional
payment models in
health care.

Does not list
traditional
payment models
in health care.

Lists but does not
describe traditional
payment models in
health care.

Describes
traditional
payment models
in health care.

Describes traditional payment
models in health care and how
quality was monitored and
rewarded under each model.

Describe current
trends in health care
payment models.

Does not list
current trends in
health care
payment models.

Lists but does not
describe current
trends in health care
payment models.

Describes current
trends in health
care payment
models.

Describes current trends in
health care payment models and
how quality is monitored and
rewarded under each model.

Explain reasoning
for newer models of
reimbursement in
health care.

Does not attempt
to explain
reasoning for
newer models of
reimbursement
in health care.

Attempts to explain
reasoning for newer
models of
reimbursement in
health care, but the
explanation is
inaccurate, illogical,
or invalid.

Explains
reasoning for
newer models of
reimbursement in
health care.

Explains reasoning for newer
models of reimbursement in
health care, and provides
relevant examples, supported by
current scholarly or professional
sources.

Compare and
contrast how quality
outcomes are
rewarded under
traditional and
current payment
models in health
care.

Does not
describe how
quality outcomes
are rewarded
under traditional
or current
payment models
in health care.

Describes but does
not compare how
quality outcomes
are rewarded under
traditional versus
current payment
models in health
care.

Compares and
contrasts how
quality outcomes
are rewarded
under traditional
and current
payment models
in health care.

Compares and contrasts how
quality outcomes are rewarded
under traditional and current
payment models in health care,
and provides relevant examples
supported by current literature.

Explain quality
concerns affecting
reimbursement
given a specific
patient scenario.

Does not identify
any quality
concerns
affecting
reimbursement
given a specific
patient scenario.

Partially identifies
quality concerns
affecting
reimbursement
given a specific
patient scenario.

Explains quality
concerns affecting
reimbursement
given a specific
patient scenario.

Provides a comprehensive
explanation of quality concerns
affecting reimbursement given a
specific patient scenario and
makes recommendations that are
supported by current scholarly or
professional sources.

Adhere to the rules
of grammar, usage,
and mechanics.

Does not adhere
to the rules of
grammar, usage,
and mechanics.

Errors in grammar,
usage, and
mechanics inhibit
readability and
comprehension and
detract from good
scholarship.

Adheres to the
rules of grammar,
usage, and
mechanics.

Exhibits strict and nearly flawless
adherence to the rules of
grammar, usage, and mechanics.

Apply APA
formatting to in-text
citations and
references.

Does not apply
APA formatting
to in-text
citations and
references.

Applies APA
formatting to in-text
citations and
references
incorrectly or
inconsistently,
detracting
noticeably from
good scholarship.

Applies APA
formatting to in-
text citations and
references.

Exhibits strict and nearly flawless
adherence to APA formatting of
in-text citations and references.

7/31/22, 9:06 PM Sample Memo // Purdue Writing Lab

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Sample Memo

TO: Kelly Anderson, Marketing Executive

FROM: Jonathon Fitzgerald, Market Research Assistant

DATE: June 14, 2007

SUBJECT: Fall Clothes Line Promotion

Market research and analysis show that the proposed advertising media for the new fall
lines need to be reprioritized and changed. Findings from focus groups and surveys
have made it apparent that we need to update our advertising efforts to align them with
the styles and trends of young adults today. No longer are young adults interested in
sitcoms as they watch reality televisions shows. Also, it has become increasingly
important to use the internet as a tool to communicate with our target audience to show
our dominance in the clothing industry.

Internet Advertising

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https://adssettings.google.com/whythisad?source=display&reasons=AS7gl4J-EhqCCtNB0tGPvSZ_2HE5bMB4lhiOk_K2NPeO_Fd27WWwf_kGpG5r0fb64aGFL7yzyqLLjNnitRlsGrKzS639PkFhgLYTHNUOk_znzmSNC322HiBissSRNxmxd3KX7-G4jtHeUcT09zObtmb-LeFa8PNTQ9vMBPqeRae94US9xd-3y-L5ciGfS8SGwJY8PlSIjLHUJE5UhIL0M_QNpsH46-xMvjVQDfgjlPqfScsUbsAD4jQCnhD_kYubH7r9pKvx8C7mlsakx5mirqGcgoOpF4GOZrP1KeV3l-T0Z0YaScGwDrsVBa4FLkPKY8xLtdrs_1bcHzfaSGud-RbQVfW9Zi909cpNqX7vQwx6_PVLo8PWxqLSS-quLDJOokFi36HRTniI5GmDndlYoye_iRjoUIQsYQ23LqMXw7_McYbevDisU4XL6ysoO5L-Rr6O4NnJjiljoT7n9OCswL9dZOV7CU4Cf5xCi52MkCNU4MuGjeHuJstgqkbMMTkzyVlCJhneT08nSAR5gG_qE5f10tkRQHf-fBthL2Ey6D_jioHkXvhMfDIBwTeHRJVUyCUkjSWSX0SaRVYGSMOyW6WDCi8fLGvXT7X0A_j1pBr_7teDuUkQod8_S3yB4xtV9HqbpbS9-Vp1zFq7pEeXK8DzNEgQ_ZUaZm5QrTt9270NEq2w-fh49oHm5ZqxCLB3rcAFjEGxRyl40VKgxm43Q7q3FaNMLw9XBhZw-T8XjbWlX8VQpcJRRv9L32GmAtCr_iNSbshjoRvqYxi5fshN4YyuUuQwzzoKf3JjmGtcHSYUBT-1R-FNDG7u4VwP5nCoyepPWy13YNHCjE4pmpuEHMlAy4Gt9mvXG27-HNTKItWXIAH6HTrpXbTNiqcbPg-k_pnKxTUD3m5HhJdT7DCBCEBK5F6r9JsNk1ysDL7_8Fkog5vCseIjraa9-lmfHywQ1-jPyABVjQ0KWpnD5OdtNt_tMcIVEEL8XwaOyYiN7y0faRAoTFNfnILLj9MmQ26ufkOGGoaf0e_cbg21EQaA7psHafOt455XvB3Y9ed3sw2PYzduM9KuX0MypUaKFy3W4p3POJl9LaAPT5EHnnZMb3kBAHBIm2TtSKUYfbrctAHx_pwrmwglec_GfHLDpmpoPmNh1qozdcl6Wl5SPLteSWbzWHPT67G001dqWh6zPOjjgJhpAnTjYN8grwnq_6o7fSSB8OTwDQPHgYZnGsl7smon6ZELL_Gy-yMEd2bfpw9ta3SzIYQ-r2RlAw78X0k54riAuS1wxCuPyTSJn_DcZkVWfO3LiJalldXhaIEG4erkqAVNXf4aRpp-Cj-QfgAE0MqHwCMqXwm9edOzs4M7ZbyzdDRNK8w_YspucBzhU3b0jG_-bgxBe1hOOdkNIvpB5MKDACF29LdEizf9-AbKbSH7zR18MNcJocS7Ge6GbBhTKEhZmRURs3TzyuvO28xjr1disjyr7GIG-0doUJacB1zV7-mrClhOavBlUzoJPqaDgqOfWwthUBxelRduQKXJAQQ2eZqgOWupbqReUHd5T2NN-HK7aGjXpmfkT2zbNclKwmYIioXbskWyfoFPt9sL3nJuFyhyZjqS4xVv77mnfSQC2qlUIlXNm7riuyHnQmqzLPv-yhoDDM7TBVbC_KnflgfRf4lpJjvSbJlWh6Jzm54hBD2XHfFvZ11eDXN2-8Tkdg-wT1Sg43tgG7mXkKGBTG5GaIDN6Mm_WnHPhVRgXWXFcra30uyboRMXLGBspYXfvsXjqG7FRXlapzztmSUFdeLxCD8ZRnxEbojMVkBupF0

7/31/22, 9:06 PM Sample Memo // Purdue Writing Lab

https://owl.purdue.edu/owl/subject_specific_writing/professional_technical_writing/memos/sample_memo.html 2/2

XYZ Company needs to focus advertising on internet sites that appeal to young people.
According to surveys, 72% of our target market uses the internet for five hours or more
per week. The following list shows in order of popularity the most frequented sites:

Google
Facebook
Myspace
EBay
iTunes

Shifting our efforts from our other media sources such as radio and magazine to these
popular internet sites will more effectively promote our product sales. Young adults are
spending more and more time on the internet downloading music, communicating and
researching for homework and less and less time reading paper magazines and listening
to the radio. As the trend for cultural icons to go digital, so must our marketing plans.

Television Advertising

It used to be common to advertise for our products on shows like Friends and Seinfeld
for our target audience, but even the face of television is changing. Young adults are
tuning into reality television shows for their entertainment. Results from the focus
group show that our target audience is most interested in shows like American Idol, The
Apprentice, and America’s Next Top Model. The only non-reality television show to be
ranked in the top ten most commonly watched shows by males and females 18-25 is
Desperate Housewives. At Blue Incorporated, we need to focus our advertising budget
on reality television shows and reduce the amount of advertising spent on other
programs.

By refocusing our advertising efforts of our new line of clothing we will be able to
maximize the exposure of our product to our target market and therefore increase our
sales. Tapping into the trends of young adults will help us gain market share and sales
through effective advertising.

Attachments: Focus Group Results, January- May 2007; Survey Findings, January –
April 2007

This is a sample memo; facts and statistics used are fictional.

7/31/22, 9:04 PM Vila Health:

Investigating a Readmission

https://media.capella.edu/CourseMedia/bhafpx4009element18870/transcript.asp 1/5

Vila Health ® Activity

Investigating a Readmission

Introduction

A Delay in Payment

The First Visit

Records Check

Conclusion

Introduction
You are a reimbursement analyst at St. Anthony
Medical Center. Reimbursement for a patient case
is overdue, and you’ve been assigned to find out
what problems, mistakes, or omissions might have
caused the delay.

A Delay in Payment
It looks like you have email from Troy Holland, Director of

Patient Services at the hospital. Click on the icon to read it.

Email
From: Troy Holland, Director of Patient Services

Subject: Case #1149923

Hi,

7/31/22, 9:04 PM Vila Health: Investigating a Readmission

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We’re having some trouble getting reimbursement on the

above patient case, and I’d like you to look into it and �nd out

what’s going on.

The patient presented at the ER last month with symptoms of

tingling sensation in the face, blurred vision, and other

symptoms that suggested an epileptic seizure event. He was

discharged, but 24 hours later, he was back – and this time, he

was diagnosed as having an ischemic stroke.

Can you investigate this? Obviously, we need to get that

payment reconciled, but I’d also like to know if there are any

quality issues regarding the care the patient received that led

to the delay in payment. Let me know if there are, so that we

can get them addressed and keep this from happening again.

Thanks.

Troy

The First Visit
A patient presented at the ER with symptoms that indicated an

epileptic seizure. Select each conversation to continue.

Registration Desk
Registration Specialist: What’s your date of birth, sir?

Patient: September 17, 1957.

[“6/17/57” entered into Hospital Records]

Registration Specialist: And do you have insurance?

Patient: Yes, Blue Cross Blue Shield.

[Hospital Records list patient’s insurance as “Anthem”]

7/31/22, 9:04 PM Vila Health: Investigating a Readmission

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Examination Room
Doctor: Symptoms include tingling sensation in the face, ‘not

feeling good,’ confusion, and muscle pain.

Patient: My face feels numb and I can’t see very well.

Doctor: I see that you have a history of epilepsy and seizures. I

think you’ve had an epileptic episode. We’ll make sure you’re on

the right dose of seizure medication, and send you home with

some meds for the muscle pain.

[Medical Device Report: 780.31, Febrile convulsions (simple),

unspeci�ed]

Records Check
When you dig into the records for both visits, you �nd the

following information. Investigate the scene to continue.

Letter from Insurer
We are the payer for patient 1149923. We have received two

bills for this patient with dates of service that are 24 hours

apart, and we are concerned with the quality of care the

patient received on the �rst visit. As a result we are requesting

medical records from the patient’s �rst and second visits to

your Emergency Room.

Physician Supervisor
Yikes. The nurse’s notes say that about 17 hours after

discharge from the ER, the patient returned with a severe

headache, increased slurring in speech, and tingling in his right

7/31/22, 9:04 PM Vila Health: Investigating a Readmission

https://media.capella.edu/CourseMedia/bhafpx4009element18870/transcript.asp 4/5

arm.

Physician
Whoops. Looks like discharge planning included a 24-hour

follow-up call to make sure the patient scheduled a primary

care visit, but I don’t see any record of that call being made.

Nurse
I don’t see any orders for diagnostic testing on the �rst visit,

and it doesn’t look like they even sent him to the observation

unit before sending him home.

Conclusion
You have completed the Vila Health: Investigating
a Readmission activity.

Delays in reimbursement can be costly for a health care

organization.

Re�ection Questions
What problems did you observe that
might lead to delays in
reimbursement — or even
nonreimbursement or �nes?

Your response:

This question has not been answered yet.

7/31/22, 9:04 PM Vila Health: Investigating a Readmission

https://media.capella.edu/CourseMedia/bhafpx4009element18870/transcript.asp 5/5

Licensed under a Creative Commons Attribution 3.0 License

(https://creativecommons.org/licenses/by-nc-nd/3.0/)

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