Milestone Three PDF

Preview

Summary

Milestone Three...

Description

RUNNING HEAD: MILESTONE 3

1

Milestone 3 Victoria Harrison Southern New Hampshire University

MILESTONE 3

2

The collection of data by patient access personnel is one of the most important parts of the billing and collection process. That data is used to ensure that the patient is being billed for the correct procedures or supplies/medications used. If these are billed incorrectly then the insurance company has the right to deny the claim. The documentation supplied by the patient access personnel is also needed in order to substantiate any claim submitted to the insurance companies. Correct documentation also bolsters exceptional customer service because if everything is billed correctly and there are no questions about billing then the patient feels comfortable with our facility and knows we did our jobs correct. Third-party policies would be used to determine exactly what the charges need to be in the charge master. We would analyze all the data to determine which would give us the maximum reimbursement. There are five areas of importance for timeliness and maximization of reimbursement, they are: Patient access, reduce denials with accurate information, employ eligibility tools, increase visibility into patient’s responsibility, check patient’s propensity to pay, collect before the instance of care, and financial triage strategies. All patients would need to have a member of the follow-up staff contact them within 2448 hours of their discharge from the facility. During this phone call the patient needs to be asked a specific set of questions: their current health status (i.e.- how are they feeling), any issues with medications, if they have follow up appointments set up, and if they have any questions or concerns. All interactions need to be documented within the patient’s medical records, this includes any previous attempted made at contacting the patient or any other action taken by a

MILESTONE 3

3

staff member. Documentation in the chart will also allow management, or a specialty team put together by management, to monitor the information for quality control and to recognize where improvements could be made.

“The purpose of a compliance program is to promote the prevention of criminal conduct, enforce government rules and regulations, while providing quality care to patients. Compliance programs can help protect practices against improper payments, fraud and abuse, and other potential liability areas. “ [ CITATION Zab16 \l 1033 ] The ACA has seven core elements for an effective compliance program, the first being the establishment and adoption of written policies and procedures to promote the organization’s commitment to compliance. This provides a written guide for employees. The second step is the appointment of a compliance officer. This person will be responsible for monitoring compliance efforts and enforcing practice standards. Next, the company needs to establish reporting systems to encourage individuals to make complaints regarding compliance items without fear of retaliation. The fourth step is ensuring that all staff members are educated and trained. Step number five is making sure that there is consistent monitoring and auditing of the compliance program to make sure it is effective and to resolve any issues. The second to last step is to enforce standards of conduct and make sure there are disciplinary measures for non-compliance. The final step is making sure all potential violations are corrected and vulnerabilities are addressed.

Managed care contracts are an important part of a healthcare organizations financial outlook. “Managed care dollars can represent a significant percentage of a healthcare organization’s revenue, and successfully negotiated contracts can not only preserve revenue but yield additional dollars through new insurance products and models. Strong managed care contracts can also

MILESTONE 3

4

enhance patient satisfaction because they facilitate patient access to comprehensive treatment and services.” [ CITATION Veg17 \l 1033 ] The most important part of the negotiation process is setting goals for the managed care contract payer-provider relationship the organization wants. For example, if we wanted to enter a long-term contract our goals would be different than if we were entering a short-term contract. In the negotiation process the healthcare organization also must look beyond rates and just departments in the hospital facility. “…increased rates in certain settings can offset decreased rates in others. By looking at the net changes across the organization, you can negotiate more effectively and realize a robust agreement for the entire organization. That includes incorporating other entities, such as ancillary providers and physicians in the negotiations” [ CITATION Veg17 \l 1033 ]

Managed care contracts are most successful for a healthcare organization when every employee completes their duties not only accurately, but also in a timely manner. This includes making sure that every procedure is has the appropriate ICD codes and CPT codes attached so that there is no delay in reimbursement. Another is making sure that documentation is correct. Prior to negotiating a managed care contract, I believe it would be beneficial to discuss specifics with multiple departments. These department may include insurance verification, billing, clinical, medical records, registration and prior authorizations.

Managed care contract can account for a large amount of a healthcare organizations overall revenue for the year. Paula Dillon, director of managed care of Rockford Health System, discussed how much her facilities can rely on managed care. “Approximately 30 percent percent of our revenue comes from managed care, so it is very important we establish positive working

MILESTONE 3

5

relationships with our managed care payers” [ CITATION Veg17 \l 1033 ] Maintaining these managed care relationships is very beneficial for the healthcare organization and its revenue.

“Recent reports indicate that in 2017, a healthcare organization’s financial health and credibility will be inextricably linked to coding compliance. Non-compliance can lead to severe penalties. Therefore, providers and medical coding companies must have the right systems and processes in place to ensure that their coding resources are kept up-to-date.”[ CITATION Cle17 \l 1033 ] There are many resources that can be utilized to ensure billing and coding compliance. The main resource would be a compliance program. This program would train employees on proper billing and coding procedures. With this program you can also evaluate employees and determine if there are any errors that need to be corrected. The next step would be evaluating what the healthcare facilities overall audit risk is. This could be achieved by hiring an independent group to ensure that all regulations are being met. The organization also needs to make sure that the employees are continuously updated with the most up to date coding, rules and regulations. By ensuring billing and coding compliance medical claims will be reimbursed faster. “If a claim is denied this may result in poor patient care, therefore it is important that the claims are correctly processed to deem improved quality of care. It is important to document the correct codes, and use ethics to correctly complete claims, as reimbursement is important to continue caring for patients” [ CITATION Har162 \l 1033 ] If billing and coding regulations are found to be in non-compliance the organization can be fined.

References Clements, J. (2017, January 7). Strategies to Ensure Coding Compliance in 2017. Retrieved from Outsource Strategy International:

MILESTONE 3

6

https://www.outsourcestrategies.com/blog/2017/01/strategies-to-ensure-coding-compliancein-2017.html Harrington, M. K. (2016). Healthcare Finance and the Mechanics of Insurance and . Burlington, MA. Vega, K. (2017). Successfully Negotiating Managed Care Contracts. Retrieved from HFMA: http://www.hfma.org/Content.aspx?id=16658 Zabel, L. (2016, July 6). 7 Elements for an Effective Healthcare Compliance Program. Retrieved from Physicians Practice: http://www.physicianspractice.com/compliance/7-elements-effectivehealthcare-compliance-program...