7-2 Final Project Submission: White Paper
Student’s Name: Shellion Mitchell
Institution: Southern New Hampshire University
Course: Human Resource Management
Professor’s Name: Mark Everett, DHA, MBA
Date: 13/7/2020
Table of Contents
- Reimbursement and Revenue Cycle
1.1 Reimbursement
1.2 Flow of patient
- Departmental impact on reimbursement
2.1 Impact of the department on the reimbursement
2.2 Department Activities that Affect Reimbursement
2.3 Department responsible for compliance with billing and coding policies
- Billing and reimbursement
3.1. Analysis of data collection
3.2. Third-Party Policies Analysis
3.3. Key areas of review
3.4 Ways to structure follow up staff in terms of effectiveness
3.5 plan for periodic review of procedures
- Marketing and Reimbursement
4.1. Strategies used to negotiate new managed care contracts
4.2. Roles of each individual regarding managed care contracts
4.3. Effect of new managed care contracts on healthcare organizations reimbursement
4.4. Resources needed in coding and billing compliance
Index: References
Reimbursement and Revenue Cycle
- Reimbursement
Reimbursement in healthcare is basically the money paid for the healthcare services that the patient has received. These reimbursements are made to facilitate running of financial operations in the health organization that may include purchasing of supplies, incurring for the daily bills, and payment of staff necessary for running of health care institutions (Singh & Wheeler, 2012). These payments can be made in any department of the institution, but that is dependent on the financial guidelines in the health institution. As the Patient Financial Services (PFS) supervisor, the core functions performed are monitoring and analyzing the process of the reimbursement, and suggesting necessary changes that will enhance the betterment of the reimbursement system. Reimbursement is necessary for a health care setting because if services were provided free of charge, it would imply the malfunctioning of the healthcare institution. Reimbursements can be made by health insurance companies, or sometimes directly from the pockets of the patients. For efficient and effective healthcare services, reimbursements should be made on time and duly.
- Flow of Patient
The reimbursement process in Becker’s Hospital is initiated when the patient comes in contact with the healthcare facility untill the time of exit where payment is made. It starts with pre-registration in the outpatient department where the details of the patient are taken concerning the payment of the hospital bill. The patient is then entered into the registry. Here the consultation fee is charged, and the patient is diagnosed based on the presentation. If there is a need for running lab tests or radiological imaging, the patient is also charged and added to the bill. If there is a need for emergency medication such as a patient with high blood pressure, in severe pain, or excess bleeding, medication is dispensed and patient charged. Depending on the diagnosis made and the situation of the patient, they are either discharged home on medication or admitted to the ward where further charges are made on bed, food, nursing care, tests run, medical reviews, etc. All these charges are captured, reviewed, and coded depending on the diagnosis of the patient and care given. At this point, the follow up of a third party is done to facilitate payment collection on behalf of the patient, claim submission, or even request the patient for self-payment where insurance does not cover. Lastly, the revenue management processes the remittance of the revenue. This body ensures that the patient is not frustrated by complex medical billing processes and handles each patient individually, ensuring all due payments are made. This ensures the financial sustainability of the health facility through profitability and equity growth (Singh & Wheeler, 2012).
Departmental Impact on Reimbursement
- A) Impact of Departments on Reimbursement
There is a significant impact that each department has on the reimbursement process, especially in regard to the time, and money brought in and taken out of the system for each department. Departments are required to follow the institutional policies in place by capturing the essential information to avoid negatively costing the organization’s reimbursement. Proper management of reimbursement processes influences the health institution’s profitability which in turn affects the effectiveness and efficiency of operations run in the institution (National Academy of Sciences, 2009). Lack of proper management, therefore, translates to increased billing costs, dropping of collection rates, and, thus, increased receivable accounts. Organizational departments play a key role in the proper management of the reimbursement process, enabling the health institution to obtain all-round control, and enhance good inter-relationship between the healthcare providers and their patients. Regular audits on departments are needed to ensure that a complete and accurate coding system is operational. HCPCS/CPT codes need to be used accurately and timely to generate the Ambulatory Payment Classification (APC) groups. The regular audits, therefore, will see that APC is successfully used in payment of the organization. Another important audit is the periodic follow-up. This audit plays the role of ensuring the health organization is able to identify, review, and rectify poor practices that affect the profitability of the organization by pointing out potential factors and compliance. The follow-up audits also play the role of ensuring the billing and coding processes are accurate and of high quality. The use of quality score metrics helps determine the effectiveness of pay for performance, which in turn helps improve the quality of the organization’s healthcare.
- B) Departmental Activities that Affect Reimbursement
There are key departmental activities that determine the success of the reimbursement system in an organization. For instance, the organizational models used should be efficiently supporting the billing activities and management of claims. A centralized billing model is thought to be more advantageous in that it provides economies of scale; there is dedicated expertise, consistency is maintained, there are standardized reporting and monitoring, as well as enhanced technological systems. In this case, adequate knowledge among the healthcare staff in different departments is also very essential. Educating the staff about the need for value-based care payment improves patient care, which in turn improves reimbursement. There is also the role of the linkages build between people, infrastructure, and processes in the revenue cycle (National Academy of Sciences, 2009).
In a bigger picture, activities within the department should reflect a reimbursement system that is scalable, well-coordinated, with a vigorous functional management system. The training of the staff should be up-to-date to boost their dedication and enhance professional billing. How much accountable are the members of every department? Front and back end accountability enhances the organization” reimbursement. It is also important to check the procedures and policies at the departmental levels to see if they are consistent, well-documented, and well understood in relation to billing and payment. Data automation has a way of enhancing unity in the departments. The department’s reporting determines if there are gaps that should be reviewed (RevCycleIntelligence, 2019).
Department Responsible for Compliance with Billing and Coding Policies
The health information management and coding department are rendered responsible for billing and coding adherence, in conjunction with the physicians. This is because they are the once that prepare the coded data and make it functional for all procedures, while the physicians are the ones that enter the appropriate code for each diagnosis and management procedure done to the patient. This, in turn, controls the reimbursement cycle, by ensuring service beneficiaries pay for the services rendered and thus ensure financial sustenance of the health organization (Becker’s Hospital CFO Report, 2020).
Billing and Reimbursement
Analysis of Data Collection
Collection of patient data in the patient access is considered very important in the reimbursement process. The success of healthcare reimbursement heavily depends on the patient experience and the accuracy and eligibility of data collected in the registry. Studies indicate that up to $17 billion, which is about 44% of revenues, is lost due to incorrect and inaccurate data collection. The data collection personnel has to ensure that the patient’s data obtained is complete and accurate, and if authorization is needed, they should obtain it. They should also be flexible in handling processes and workflows to avoid errors that may lead to revenue cycle denials. The coding personnel ensures proper coding, which will enable the billers to use the information appropriately to bill the patient or the insurance company. The analysis should be done on three levels; estimate the consumer effectiveness, insurance effectiveness, and team effectiveness in terms of time and cost of collection (Williams, 2017).
Accurate data in a healthcare setting is the major determinant of the quality of healthcare offered. The high-quality customer care service plays a role in setting the standards of healthcare quality offered in the institution. It establishes long-lasting relationship between the institution and the patients. This requires that the healthcare workers in an organization all play the role of customer care personnel and treat every patient as an individual whom the organization is intended to help rather than as a customer. The customer care is expected to offer quality and efficient healthcare, in a caring, professional, confident, and empathetic manner offered in a comfortable environment. This makes the patients recognize the organization as an outstanding healthcare facility, which they will be comfortable revisiting severally and paying for services offered without any difficulty (Michael, 2020).
Third-Party Policies Analysis
Third-party policies are used to determine clean claims and the timeliness of payment. It also identifies penalties for failure of the third paying insurance company to reimburse the healthcare organization. The policies and guidelines in place help healthcare organizations to claim for their due payments. The policies also stipulate compliance guidelines that prevent, detect, and resolve any form of misconduct in healthcare organizations. It enhances accountability and maintenance of ethical practices in the billing process; and enhances internal quality control in billing and reimbursement.
Key Areas of Review
Various components of patient-interaction related to revenue and reimbursement need to be reviewed, and proper ways have to be established to reduce the gaps that contribute to loss of revenue. The areas that harbor the gaps are the pre-service, the care process, the integrity practices which include clinical documentation and coding compliance, the billing services entailing the patient support, the follow-up, and collections of payments, and finally the administrative services that include contract management, collections of debt, schedules of fee, management of denial, and management of care contracts. For reimbursement improvements, the focus has to be based particularly on the three core areas, which are: the technical, the financial, and operational processes. On the technical part, we ought to focus on application systems that include the patient to provide interaction and EMR. In the financial sector, it is very key to focus on handling the collection of funds and denials. Last but not least, the operational part requires that proper staffing, organizational workflows, and vendor relationships are done (RevCycleIntelligence, 2019).
Eligibility tools are useful in ensuring cost-sharing and calculating the probable deductible. Patient’s financial capability is also essential in making them take their medical financial responsibility. This will, in turn, make the healthcare be able to calculate the amount of reimbursement that they should expect. Improving the reimbursement collection rate may also require that payment may be collected prior to service delivery, which will highly reduce the amount lost through denials.
Ways to Structure follow-up Staff in Terms of Effectiveness.
Structuring and training your staff in the follow-up of denials is essential in ensuring maximum reimbursement. This is done in three phases:
Initial Evaluation
1
Analysis and Prioritizing
2
Collection
3
The staff is first involved in the analysis and identification of the claims. The staff will then have to review the policy of the provider and identify those claims that need to be adjusted off. The second stage requires that the identified claims are prioritized as uncollectable and have not been paid as agreed in the contract. The claims are then re-filed after the billing information has been verified then followed up for collection. In all this process, the healthcare staff must keep reliable information about the patients, which includes their diagnosis, the care they received, and the follow-up. Monitoring also plays a key role in quality improvement in a health organization. Therefore, the monitoring team determines the achievement of the expected outcomes by the health organizations, and integrating measures that enhance staff accountability and achievement of set goals (HealthCare BPO, 2020). As the supervisor, I will structure staff team that ensures communication is enhanced among the staff, creating a robust billing system, having multiple departmental members, and having systems that complement the billing system.
Plan for Periodic Review of Procedures
According to MedPro Group (2018), a compliance plan is not only required by the law; but is also important in the prevention of erroneous billing, and fraudulent claims, prepares the organization for audits and also protects the organization from having ethical conflicts between the patient care and profitability. For compliance, the plan entails seven key procedures. Firstly, the organization should implement the conduct’s written policies, procedures, and standards. Secondly, there should be a designated compliance committee and officer who will be responsible in overseeing the program. Thirdly, the delegation of authority will be done in due diligence. Fourthly, there will be frequent education of employees and the development of effective communication strategies. Fifthly, internal auditing and monitoring will be done to determine the effectiveness of strategies and the achievement of set goals. Sixthly, standards will be enforced in proper disciplinary guidelines. Finally, whenever mistakes are detected, a quick response will be launched, and corrective measures are taken.
Marketing and Reimbursement
Strategies used to Negotiate New Managed Care Contracts
The healthcare organization has to set goals for the relationship, depending on whether it is a long term or short term relationship. Most of the managed care contracts finance up to 30% of the organization’s revenue, and thus is important to build an important relationship (Vega & Dillon, 2013). The organization should also look beyond the rates of compensation. Check for other factors such as the responsiveness of the payer to problems claims, and how wide the products the payer is offering. The organization should also focus on the net effects of the payments rather than focusing only on the hospital, look at the bigger picture. The organization needs to know the comprehensive payer profile to be prepared to deal with them and keep your options open, this way, both the payer and the service providers will be on the winning end.
Roles of each individual in regard to managed care contracts
All individuals in this institution, including healthcare providers, sponsors, etc. play key roles in managed healthcare contracts. The healthcare providers for instance, provide information on the responsiveness of payers, their willingness to solve problems, and their willingness to pay for medical costs. The billing personnel bill the insurance payer, while the denial organization health personnel deal with the follow-up of denial revenues.
Effect of New Managed Care Contracts on Healthcare Organizations Reimbursement
A managed care contract pays a significant amount of money to healthcare organizations and therefore it contributes a lot to the financial capability of the organization. The organization can utilize insurance models and products, which are an additional source of revenue. This will improve the quality of services and thus, customer satisfaction.
Resources Needed in Coding and Billing Compliance
Guidelines provided by the Healthcare Insurance and Accountability Act are useful in ensuring organizations follow the right procedures in coding and billing processes. For instance, no service or procedure should share a code; each should have a unique code. This way, errors are reduced, and the payer or insurance companies will easily comply with the payment. A standard system is also needed in the claims processing. A multi-disciplinary committee also helps in bringing in different inputs in the panel.
References
Becker’s Hospital CFO Report. (2020). 3 steps hospitals must take with their coding compliance policies: When is the last time your hospital, health system or organization looked at codes and clinical documentation to ensure everything was compliant with the law and best practices? Becker’s Hospital Review – Healthcare News. https://www.beckershospitalreview.com/finance/3-steps-hospitals-must-take-with-their-coding-compliance-policies.html
HealthCare BPO. (2020). Why is a/R follow-up crucial in medical billing. Outsourcing to India | FWS – Flatworld Solutions. https://www.flatworldsolutions.com/healthcare/articles/ar-follow-up-importance-medical-billing-process.php
MedPro Group. (2018). Developing an Effective Compliance Plan: A Guide for Healthcare Practices. The Leader In Healthcare Malpractice Insurance | MedPro Group. https://www.medpro.com/documents/10502/2837997/Guideline_Developing+an+Effective+Compliance+Program.pdf
Michael, M. (2020, May 18). Importance of great customer service in healthcare and how to provide it. Freshdesk Blogs. https://freshdesk.com/help-desk-software/healthcare-customer-service-blog/
National Academy of Sciences. (2009). Health databases and health database organizations: Uses, benefits, and concerns – Health data in the Information Age – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK236556/
RevCycleIntelligence. (2019, December 18). Key ways to improve claims management and reimbursement in the healthcare revenue cycle. https://revcycleintelligence.com/features/Ways-Improve-Claims-Management-and-Reimbursement-in-the-Healthcare-Reve
Singh, S. R., & Wheeler, J. (2012). Hospital financial management: what is the link between revenue cycle management, profitability, and not-for-profit hospitals’ ability to grow equity?. Journal of Healthcare Management, 57(5), 325-341.
Vega, K. B., & Dillon, B. R. (2013, April 24). Successfully negotiating managed care contracts. hfma. https://www.hfma.org/topics/trends/16658.html
Williams, J. (2017, June 26). Patient access and analytics: Perfect together. HealthLeaders Media. https://www.healthleadersmedia.com/finance/patient-access-and-analytics-perfect-together