IHP 6309-1 Final Project

pptx

School

Southern New Hampshire University *

*We aren’t endorsed by this school

Course

630

Subject

Business

Date

Feb 20, 2024

Type

pptx

Pages

Uploaded by belkisa05

IHP 630 Final Project Belkisa Alic Southern New Hampshire University 1

AGENDA Strategic Planning Staffing Healthcare Reimburseme nt Revenue- Cycle Process Reimburseme nt compliance Recommenda tions 2

INTRODUCTION This presentation will touch on the strengths and weakness of each healthcare category. We will also discuss how to improve the financial aspects of the organization on the reimbursement category. 3

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Strategic Planning 4

Strategic Planning 5 What is Strategic Planning and why is it important? • Strategic Planning is the foundation of the organization. It lays down the ground rules for determination of the success of the organization. • “Strategic planning provides the structure to make day-to-day decisions that follow a larger vision, creates a direction for your practice, and maximizes your options for influencing your environment (NIH, 2009).” • The importance of strategic planning is there to help us understand our financial management, daily decisions, which has staff collaborate on projects and new innovations. • Strategic planning helps us create a direction for which the organization can maximize its options and decisions with the environmental changes along with medicine moving in a fast environment with all the new changes.

Financial Management Principles 6 Key Principles Budgeting Planning Financial evaluation of available funds Compliance “Healthcare financial evaluation and planning, budgeting and forecasting, generating revenue, mitigating risk, detecting fraud, and complying with regulations. The financial management function is also responsible for producing regular financial reports, as well as performing various types of analysis of the healthcare organization’s finances for use by internal leaders and managers and external stakeholders (Luther, 2023).”

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Collaborative Teamwork Integration 7 Collaborative teamwork plays an important role in healthcare as it takes many different departments and people to be able to have the organization run smoothly. Team player Working collaboratively includes communicating with one another In depth understanding of the vision, mission, and goals Clear understanding of the role and its responsibilities Speaking up, supporting one another, and department meetings to bring forth concerns and how to address them

Staffing Impact 8 When we are looking to staff different departments, each one has its own criteria and educational requirements. Staff needs to have great customer service. When staffing for the billing team, the requirements are: experience, certification, compliance, training, and communication. “Data and analytics are the lifeline for successful, sustainable revenue cycle management, but optimization can’t stop there. Tracking the right metrics, promoting accountability, creating consistent workflows, and identifying the right KPIs—all based on the right data—are necessary for health systems to optimize revenue cycle and achieve higher profit margins. With the right processes that turn data into action, leaders can focus on achieving the optimum revenue cycle model (Dazley & Halpin, 2020).” “Revenue cycle leaders need to comprehend that data and metrics don’t equate to information. Data and metrics are the building blocks to reach meaningful information, but a crucial in-between step is developing key performance indicators (KPIs) (Dazley & Halpin, 2020).” With all of this being stated each department from the revenue-cycle must keep open communication and close the loop on each category to make sure there is no fall through. Detail oriented,

Healthcare Reimbursement 9

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Healthcare Reimbursement 10 Value Based- Value-based care is a form of reimbursement that ties payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness. This form of reimbursement has emerged as an alternative and potential replacement for fee-for- service reimbursement, which pays providers retrospectively for services delivered based on bill charges or annual fee schedules (LaPointe, 2022). Fee-for-service- the traditional fee- for-service reimbursement model promoted the quantity of services, federal officials have proposed several reimbursement programs that reward healthcare providers for the quality of care that they give to patients (LaPointe, 2022).

Improvement Processes 11 Express the importance of KPI, collecting payments in front-end revenue cycle Each department has checklist sign off for their tasks for the day, week, month Review and utilize data collected Adjust workflow if necessary, bring in third party to review charges, and do audits Review current reimbursement policies and make changes and adjustments based on the revenue cycle for the organization

Payor Model Advantages and Disadvantages 12

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Payor Model Advantages Government Funded • Medicare and Medicaid • Lower rate of denied claims • Less healthcare cost • Lower costs for administrative staff • More people qualify who have lower income • Prior authorization/approvals required • Stricter laws around services being rendered • No out-of-pocket cost to patients • No premium • Tax Exemption Private Insurance • More services offered • More provide availability • Larger pool of healthcare facilities/providers • Price negotiation with organizations available • Larger area of services covered • Larger pool of specialists • Multiple private insurance carriers 13

Payor Model Disadvantages Government Funded • Lower reimbursement for services • No incentives • Penalties for CMS violations • Smaller pool of healthcare facilities/providers • Longer wait times for appointment with specialists • Medicaid pays 88 cents on the dollar for services (AHA, 2020) • Medicare pays 84 cents on the dollar for services (AHA, 2020) Private Insurance • Larger patient responsibility financially • Higher denial rate • Payment is dependent on coverage • Higher premiums • No financial penalties for non-met requirements • High deductible • Out-of-pocket cost to the patient 14

Managed Care Plan Advantages and Disadvantages Advantages • Lower financial burden to the patient with great care still being provided • Patient centered care • Coordinated plan for care amongst providers • Good reimbursement rate • Easily accessible charts with other facilities • Access to providers 24/7 • Care management teams • Health and wellness programs • Nurse lines • HMO and PPO plans • Quick in-network referrals Disadvantages • Lower reimbursement rate • Longer reimbursement turnaround • Patients being treated a numbers vs people • Longer wait times for appointments due to less availability of providers • Laws are more strict • Patient self advocates 15

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Revenue Cycle Process 16

Models and Methods Models • Reduce billing errors • Ensure smooth payment processes • Lessen payment delays • Timely manner of prior-authorization approvals • Timely charge capture to ensure billing is done correctly • Insurance verification Methods • Upgraded EMR system/ billing software • Increase staffing • Prior to appointments, checking insurance eligibility • Claims review • Audits of charge capture • Upgrade systems for prior authorizations • 6 week training program for new employees • Early verification of demographics and insurance coverage to be done2-3 days prior to appointment 17

Workflo w assessm ent findings 18 Front-end staff to check eligibility prior to appointments to minimize errors during the appointment time Middle-end staff would start a new streamline of how to simplify the workload and verification of missing clinical information Back-end staff would utilize a new electronic system to collect payments along with running electronic prior authorizations for services Management team would wok on having open and effective communication Put in place new policies and procedures to minimize the workload but make it efficient with the software and EMR systems Provide proper and thorough training Provide education to providers on proper code selectin and charge drop

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Reimbursement Compliance: Regulations Federal Regulation “HIPAA compliance laws set the standards for protecting sensitive patient data that healthcare providers, insurance companies, and other covered entities must adhere to. A key component of HIPAA compliance law is the Privacy Rule, which sets out national standards for when protected health information (PHI) may be used and disclosed (HIPAA Journal, 2024).“ Penalties for HIPAA violations can range anywhere from $100-$1.5 million depending on the type of violation that was committed. (HIPAA Journal, 2024) State Regulation As providers and hospitals begin to provide services, they must obtain consent and make sure it is completed correctly to be able to get full reimbursement for the services rendered. As Medicare is a federally funded insurance there must be consents present. “Centers for Medicare and Medicaid Services (CMS) requires that consent include the name of the hospital where treatment will take place; name of specific procedure to be performed; statement that the procedure/treatment has been explained appropriately as it relates to the risks, benefits, and alternatives; and signature of the patient or his/her representative, along with the date and time (ASHRM, 2019).” Third-Party Payer Regulation One of the regulations that has been set was when the Affordable Care Act was mandated. Each individual and small business groups had to be able to provide medical coverage that would be essential to seek care. “ The Affordable Care Act requires non- grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB) (CMS.gov).” 19

Reporting Requirements 20 HIPAA compliance Utilize EMR systems to submit claims Timely claim filing Meaningful use participation Follow CMS guidelines on overpayment/underpayment of services

Technology and System Impacts 21 Front-end revenue cycle utilizing EMR to verify patient demographics and insurance coverage Registering patients for the patient portal Software within the EMR system that would help with revenue cycles Software within EMR system to flag any coding errors

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Recommendations 22 Open communication with staff EMR system that benefits all departments from clinical to administrative Negotiations with third-party payers for prices Payment processing to be utilized with EMR Automated reminder calls/messages for appointments Automated eligibility status with insurance New policy/protocols for denied or late submitted claims Software to recognize coding errors Thorough training program and explanation of all documents to new employees

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Referen ces 23 American Hospital Association. (2020, January 7). Fact Sheet: Underpayment by Medicare and Medicaid | AHA. Retrieved June 30, 2022, from https://www.aha.org/fact-sheets/2020-01-07-fact-sheet-underpayment-medic are-and-medicaid Dazley, M., & Halpin, T. (2020, October 22). Healthcare Revenue Cycle: 5 Keys to Success. HealthCatalyst. https://www.healthcatalyst.com/insights/healthcare-revenue-cycle-5-keys-su ccess HIPAA retrieved from https://www.hipaajournal.com/ Hu, Y. (2019, January 1). Reimbursement of Engineered Products (R. L. Reis, Ed.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128012383655885 Information on Essential Health Benefits (EHB) Benchmark Plans retrieved from https://www.cms.gov/marketplace/resources/data/essential-health-benefits Informed Consent retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430827/#:~:text=Informed%20co nsent%20is%20the%20process,undergo%20the%20procedure%20or%20int ervention Land, T. 2021 The Bottom Line: Strategy Drives Financial Growth in Healthcare retrieved from https://pubmed.ncbi.nlm.nih.gov/34813510/ Luther, D. 2023 Healthcare Financial Management: An expert guide retrieved from https://www.netsuite.com/portal/resource/articles/financial-management/he althcare-financial-management.shtml#:~:text=At%20a%20high%20level%2 C%20financial,%2C%20cash%2C%20capital%20and%20control . LaPointe, J. (2022, March 2). What Is Value-Based Care, What It Means for Providers? RevCycleIntelligence. https://revcycleintelligence.com/features/what-is-value-based-care-what-it- means-for-providers LaPointe, J. (2022, March 2)What Is Value-Based Care, What It Means for Providers? RevCycleIntelligence. https://revcycleintelligence.com/features/what-is-value-based-care-what-it- means-for-providers Managed Care retrieved from

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Referen ces • RevCycleIntelligence. (2022, May 19). Hospital Prices 224% Higher for Private Payers than Medicare. RevCycleIntelligence. https://revcycleintelligence.com/news/hospital-prices-224- higher-for-private-payers-than-medicare Revenue Cycle • Management 101. (2013, December 12). NueMD. https://nuemd.com/revenue-cycle-management/rcm-101 • Management and Business Office (BO) Processes | National Rural Health Resource Center. (n.d.). National Rural Health Resource Center. Retrieved January 11, 2023, from https://www.ruralcenter.org/srht/rural-hospital-toolkit/reve nue-cycle-management-andbusiness-office-bo-processes • Shah, R. (2018, July 20). How to Improve Healthcare Revenue Cycle Management through software automation. Osplabs. https://www.osplabs.com/insights/how-to-improve-healthca re-revenue-cycle-management-through-software-automatio n/ • Strategic Plans for Guiding Medical Groups. (2022). MGMA. https://www.mgma.com/data/data-stories/strategic-plans-ca n-help-guidemedical-groups-in-t • The Healthcare Revenue Cycle: 3 Ways to Improve. (2021, April 20). HealthCatalyst. https://www.healthcatalyst.com/insights/healthcarerevenue -cycle-3-ways-improve 24

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

IHP 6309-1 Final Project

Related Documents