IHP 6309-1 Final Project Sepaker Notes

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1 Southern New Hampshire University 9-1 Final Project IHP 630 Belkisa Alic February 9, 2024

2 Introduction Within any healthcare organization there needs to be a healthcare administrator who is there to lead by example, guide their team in providing quality care, and manage revenue services. Revenue services come in different forms, from copayments, to insurance payments, to self-pay patients. there is also revenue coming in from federal funding, state, and third-party payors. When we look at how the organizations revenue cycle functions, we need to understand that reimbursement from any payor form is what helps the healthcare organizations stay afloat during tough times such as COVID. The revenue cycle itself is the foundation of any reimbursement process which provides guidance for internal and external investors/stakeholders who may be concerned about the organization’s revenue. As the healthcare administrator one of the job duties and responsibilities is to make sure to report the payments processed and how they have been made. The following paper will discuss the different topics that the administration and organization would address. We will examine the following: strategic planning, fiscal management principles, collaborative integration, staffing impact, healthcare reimbursement, improvement process, Payor model advantages and disadvantages, managed care advantages and disadvantages. The administrator will also analyze and review the revenue-cycle process, reimbursement compliance and follow up with any recommendations for new policies and procedures. Strategic Planning Financial Management Principles

3 As any organization begins to build its foundation and core, they need to establish a sense of direction for their strategic planning. “Strategic planning, the driving force behind organizational achievement, can empower your organization to navigate a complex landscape and chart a course toward a successful future. This process allows you to define your organization’s direction, align goals to ensure cohesive progress, identify areas for improvement, enable competitiveness, and cultivate areas of excellence (AAMC, 2024).” According to AAMC organizational goals need to be aligned with all parties throughout the organization to have satisfactory progress for a good outline of quality care and a strong organizational establishment. The start to any great project is to start with a plan, which would breakdown the specific of the requirements and what the organization is trying to achieve. AAMC states that to start off on a good note we must begin with a clear message of what the scope of plan is, organize the process, identifying stakeholders/investors, and putting together a board of committees who would start the initial process. As we move to phase two which includes the identifying of departments that would be included for collecting proper data needed to understand how each department work and what is necessary for their success. “A current state assessment evaluates your organization’s current position through data collection and analysis, focus groups, surveys, stakeholder interviews, and benchmarking (AAMC, 2024).” This step would help us review and finalize the organizations mission, vision, and value statement. Once each of these has been review and finalized, we would submit everything for approval. Collaborative Teamwork Integration

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4 Research is one of the areas that is crucial to teamwork, and they perform many procedures as a team. Teamwork is necessary for all areas of healthcare organizations especially on the clinical aspect of healthcare. Teamwork leads to better efficiency, collaboration, less burnout, support, and better delivery of healthcare services. Communication is a key component to any job, and I the healthcare organization it is crucial for all teams to communicate effectively to avoid any mistakes or negative impacts to the people we serve daily. “ A single visit requires collaboration among a multidisciplinary group of clinicians, administrative staff, patients, and their loved ones. Multiple visits often occur across different clinicians working in different organizations. Ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue. Health care delivery systems exemplify complex organizations operating under high stakes in dynamic policy and regulatory environments. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries (Rosen, 2018).” Collaborative teamwork plays a key role in healthcare as it takes many different departments and people to be able to have the organization run smoothly. Few other crucial factors in teamwork are in depth understanding of the organization’s missions, visions, and goals. Clear understanding of your role and responsibility, working collaboratively includes communicating with one another, and most importantly Speaking up, supporting one another, and department meetings to bring forth concerns and how to address them. Staffing Impact The primarily important aspect of any staffing is communication. As the management team who oversees the department of the revenue cycles, the candidates who are looking to begin work in the department must exhibit skills that would not only benefit the organization but also

5 the team itself. When staffing for the billing team, the requirements are experience, certification, compliance, training, and communication. When we are looking to staff different departments, each one has its own criteria and educational requirements. Staff needs to have great customer service. Further staffing competency needs to be proficient in payment collection, denials, unpaid claims, medical billing process, scheduling appointments, insurance verification, coverage benefits, and obtaining prior authorizations. As team member are being brought onto the team, they need to understand how the revenue cycle works and how it is to be managed to maintain profitability. Staffing from management, front-end revenue, middle-end, and back-end revenue cycles is all important to maintaining positive revenue, decrease amount of denied claims, and make sure all patient information is correct to be able to receive reimbursement from insurance for services provided. “Data and analytics are the lifeline for successful, sustainable revenue cycle management, but optimization cannot 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 do not 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).” Training is vital for the fresh staff members, but it is to be done on the position itself. Providing training on the ins and outs of the job is important to be able to perform to your highest ability, positive interaction with the team, understanding of the billing and coding

6 process, and how claims are submitted. “ Errors in coding or data entry, or not understanding how the job affects the revenue stream can result in a decrease in profitability. Therefore, it is important that each team member is trained not only in their own position, but in how the group functions. The RCM team should ensure that all departments involved in this process are professionally trained and knowledgeable about their role in the bigger financial picture. For example, those responsible for capturing patient data correctly need to know how to properly capture information on the front end so the data can be successfully billed for on the back end (Condon, 2017).” Healthcare Reimbursement Improvement Process “Healthcare Revenue Cycle Management (RCM) is the financial process that organizations use to manage the administrative and clinical functions associated with different steps of patient care from start to finish. The process starts when a patient schedules a visit for medical services and finishes when all claims and patient payments have been collected. With RCM in healthcare, the goal is to discover any potential problems in the revenue cycle and solve them before they become a bigger issue. It is extremely important for RCM in healthcare to run smoothly to keep your entire system working properly (Pathstone, 2024).” As the RCM team maintains the consistency of financial revenue, they must also comply with all regulations within the revenue cycle to avoid any possibility of penalties that would occur from noncompliance within the CMS guidelines.

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7 Revenue integrity is a crucial part of any organization to maintain its licensing, business, trust, and providing great care. As the RCM team is there to make sure all compensation is accounted from the federal payor, state payor, and third-party payor for the services rendered. “ Revenue integrity in healthcare ensures that all clinical encounters between providers and patients convert into revenue, by using systems and procedures that focus on effectiveness, compliance, and optimal compensation for services. As a part of revenue cycle management (RCM), it means that what is delivered is being billed and that what is billed is being delivered. All compensation owed should be captured in the most exacting and efficient ways possible (advantumhealth, 2024).” Everyday new procedures and policies are in place. New medical interventions are evolving and due to this we must make sure that the RCM process improves with the recent changes. There is and always will be a need for monitoring, auditing, adjustments, and new training to stay on top of all the changes. Moving forward we need to maintain any new onboarding, training, educational pieces, and errors made to be apart of the training to be able to capture any errors, and it will help provide a new workflow within the organization. Payor Model Advantages and Disadvantages “ A new RAND study found that in 2020, employers and private health insurance plans paid hospitals 224% more than Medicare for inpatient and outpatient services, with wide variation in prices among states. According to the report, hospital services accounted for 37% of total health spending for the privately insured in 2019 and hospital price increases are key drivers of growth in per capita spending among the privately insured. Private insurance prices relative to Medicare to compare private insurance prices to a common payer and to apply a publicly

8 available approach to fairly compare private insurance prices among different hospitals (Copeland, 2022).” “Private insurers paid 222% of Medicare prices in 2018 and 235% in 2019. In 2020, relative prices for hospital facility-only services averaged 224%, while associated professional services, such as physician fees, averaged 163% of what Medicare would have paid for the same services. In 2020, COVID-19 inpatient hospitalizations averaged 241% of Medicare, which is like the relative price for all inpatient procedures. There was significant variation across states. Some states (Hawaii, Arkansas, and Washington) had relative prices below 175% of Medicare, while others (Florida, West Virginia, and South Carolina) had relative prices that were at or above 310% of Medicare levels (Copeland, 2022).” Fee-for-service payments is a payment method for reimbursement for services provided to the patient for any procedure. One of the major advantages that fee-for-service has is that it supports accountability for the patient care, but it is limited to the scope of the service a particular physician provides at any time. Another advantage is that this type of system encourages delivery of care and to maximize patient visits, flexible and is employed regardless of the size of the organization. (Medical Billers and Coders, 2024) As we move into the disadvantage’s aspect, we know that it offers little to no incentive, limits face-to-face visits, creates a barrier to care coordination and management of conditions via other means, and last the patients suffer the coordination involved in this type of model. (Medical Billers and Coders, 2024) Managed Care Plan Advantages and Disadvantages One of the best advantages of managed care plans is that it provides access to healthcare options whenever people may need a physician. This advantage allows for access to immediate

9 services, which opens the availability for people to have full control of their care. “ Managed care is the most usual form of health care in the United States. It is available to individuals in three common formats: preferred provider organizations, health maintenance organizations, or point- of-sale care (Gaille, 2017).” As mentioned by Gaille some of the other advantages are: lower cost of healthcare for those who have access, quicker referrals within their network, availability of medical records via EMR systems, maintains relationships between providers and patients, managed care networks required various accreditation from providers, and prescription management making sure medications are available and are reasonable pricing. There are disadvantages with managed care plans as well. As Gaille stated “if your poor and living in a system with managed care, then your options are limited. People seek care in the emergency rooms due to knowing they will not be denied care. Finding providers in private practice is impossible. Managed care limits your options choosing a provider, patients are forced to advocate for themselves. Requirement of prior-authorization, unreasonable services being offered such as unnecessary bloodwork to maximize billing, and lack of privacy. Since the passing of the Affordable Care Act, more patients have been accessing local networks to receive care. Without more doctors entering those networks, longer wait times for appointments have become necessary in the busiest networks (Gaille, 2017).” Revenue-Cycle Process Models and Methods As front desk staff is the first person every customer or patient sees this is the beginning of our front-end process. The responsibility of the front-end process revenue cycle is registration, scheduling, insurance verification, provide necessary paperwork to obtain consent to treat,

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10 HIPAA, privacy paperwork, financial agreement consent, and provide the patient with a copy of the patient rights. As each of these is obtain the patient may receive services and in turn, we would bill the insurance to pay for the services rendered. “It is common for hospitals and large physician practices to include financial counseling as a service to their patients as they try to manage payment of a deductible while receiving essential healthcare services. This counseling may take many forms including offering payment plans, healthcare loans, or payment support from manufacturers of high-cost pharmaceuticals. Although tools like ABNs and patient financial liability agreements are in place, patients are often surprised by the level of out-of- pocket costs and struggle to pay them in a timely manner. This causes financial issues for both the patient and the provider. Financial counseling is one strategy to help both parties. Financial counseling is worth the cost of administering the program to help the patient find a way to pay for their share of the cost of care (Casto, 2021).” When we discuss the advanced beneficiary notice for services, this should always be obtained prior to any services rendered. By obtaining consent from the patient to render services that may not be covered they are aware that there would be a bill for their services outside of what the insurance would pay for. This holds the patient responsible and aware that there would be additional charges. Once the patient arrives to the clinic, they should be provided will all necessary paperwork, instructed on what each one is and, they should be informed of the economic responsibility. Once a patient is notified of everything and the possibility of having additional charges due to insurance not covering, at this point they can make the decision to proceed with services or not. As a healthcare facility and provider, it is our responsibility to cover all our bases and make sure we are fully transparent.

11 “As healthcare revenue cycle management continues to evolve, it is the hospital’s responsibility to maintain the highest level of patient-centric care by working as one unit. Each department must have their goals aligned to be firing on all cylinders. This requires the contract data to be accurate and a clear path of communication that ensures hospital staff knows their role in maintaining the revenue cycle. This process involves monitoring accounts that are outstanding and pursuing payment of those balances from patients. As patient fiscal responsibility continues to increase due to high-deductible health plans, patient collections are becoming more critical to revenue (Kay, 2019).” As we maintain open communication and integrity with our patients for the services provided and cost this creates a stronger relationship and trust to provide the best care possible, but it also maintains a successful revenue cycle. Workflow Assessment Findings Improving workflow affects both internal and external factors. We begin with the internal changes that would start with registration training. Reviewing current training protocols and how to improve them. Getting feedback on what staff is struggling with and how to make it better that would not cause issues with registrations, insurance verification, demographic inputting, and patient verification of all information. Once we have trained the staff on how to obtain the information, next we would work towards informing our patients of the recent changes and protocol and have the patient verify all information obtained from them via telephone. One next big step we would need to take is to have a separate department who would focus on prior authorizations in general. With having a separate department focus solely on prior authorizations, this would minimize the workload, delays, errors, and denials at the front-end revenue process.

12 Now as we go to the external process and how to fix it, this tracks right back to the EMR systems. With having a good EMR system this would help the facilities and providers communicate with pharmacies, insurance companies, status of prior authorizations, and if prior authorizations are needed for services rendered. Another recommendation that would be made is to have a back-end team who would verify the coding that would submit from the facility or providers for the services rendered. As we utilize the EMR system along with a back-end team who would verify coding as well this would decrease the number of declined claims. Each of these departments that would be put in place would have their own training that is specific to their work, which would help them be stronger I their area and know when they see an error. Reimbursement Compliance Regulations We will be discussing the importance of licensure and credentialing as one of the crucial factors of being able to provide care, incentives, paying claims, providing services to patients under Medicaid, Medicare, and private insurance. “ Licensing refers to the process of securing the authority to practice medicine within a state. Credentialing refers to the process of verifying the provider’s license, education, insurance, and other information to ensure they meet the standards of practice required by the hospital or healthcare facility(RHIhub.com).” Anytime we discuss requirements we know that the government and other regulatory parties will be involved. 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. This is a part of the Essential Health Benefits regulations. “ The Affordable Care Act requires non-grandfathered health plans

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13 in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care (CMS.gov).” One of the hardest financial impacts on the federal payer to the providers, clinics and hospitals is that they do not get much pay from the ferally funded programs. As stated by Laws in an article “Hospitals generally follow a basic credentialing and privileging framework established within the section of the U.S. Code of Federal Regulations (CFR) comprising the Public Health Service Act. However, these CFR Title 42 regulations (Conditions of Participation—CoPs) only specify credentialing and privileging requirements for hospitals to gain or maintain accreditation to participate in Medicare and Medicaid.”(Laws, 2021) What this says in layman’s terms is that the hospital will get their credentialing and licensing done to the bare minimum to be qualified to accept Medicaid and Medicare, along with receiving payments from the regulated government. As we have seen and continue to see that the CMS is making their regulations stricter to avoid fraudulent activity, we have also seen that hospitals are taking a hit in their rendered services, reimbursement rates, and increase of patients who are covered under Medicaid and Medicare. “It is broadly acknowledged that Medicare reimburses hospitals less than the cost of providing care and their reimbursement rates are non-negotiable. The Medicare Payment Advisory Commission found that hospitals experienced a -8.5% margin on Medicare services in

14 2020, and it projects that margin will fall to -9% in 2022. Combined underpayments from Medicare and Medicaid to hospitals were $100 billion in 2020, up from $76 billion in 2019. Exacerbating this pressure is the fact that Medicare and Medicaid account for most hospital utilization. In fact, 94% of hospitals have 50% of their inpatient days paid by Medicare and Medicaid and more than three quarters of hospitals have 67% Medicare and Medicaid inpatient days. Because of the fixed nature of these payments, hospitals are unable to fully absorb the tremendous inflationary forces they are currently facing. A new AHA report highlights the significant growth in expenses across labor, drugs, and supplies, as well as the impact that rising inflation is having on hospital prices. Further cutting Medicare payments to hospitals and health systems will threaten access to care for patients and communities (AHA.org).” Informed consent is a particularly important part in medicine. Any person who is to receive care of any kind they must be informed of what is being done, and with that they need to provide consent for any testing or procedures to be performed. “Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. The patient must be competent to make a voluntary decision about whether to undergo the procedure or intervention (NIH, 2023).” With state payers it is the same requirements as the federal. For Medicaid to pay in full the services rendered an informed consent must be on file in the patients record. Informed consent is one of the main factors in reimbursement for services and how much of the percentage of payment would be taken care of. “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. PHI refers to any

15 information about health status, provision of health care, or payment for health care that can be linked to a specific individual. This interpretation of PHI is broad and encompasses any part of a patient’s medical record or payment history (HIPAA Journal, 2024).” As HIPAA is a wide range and main privacy rules out there for all insurances state, federal or private the rules remain the same. No facility or provider should be violating HIPAA or the patient’s privacy in any aspect. The violations cause a ripple effect throughout regardless of the type of payer it is. The private/third-payer payers would be subject to the same penalties, fines, and reporting to the federal government. Reporting Requirements “ Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self- insurance), no-fault insurance, or workers’ compensation, collectively referred to as Non-Group Health Plan (NGHP) or NGHP insurance. The purpose of Section 111 reporting is to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Section 111 NGHP reporting of applicable liability insurance (including self- insurance), no-fault insurance, and workers’ compensation claim information helps CMS determine when other insurance coverage is primary to Medicare, meaning that it should pay for the items and services first before Medicare considers its payment responsibilities (CMS.gov,2023).” Technology and System Impacts

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16 “ Front end revenue cycle begins with patient registration and ends once payments are collected. Obtaining the correct insurance information and patient health profile upfront allows a company to develop the appropriate plan of care tailored for that specific individual. Many patients need health care right now and time is of the essence when verifying benefits and communicating patient financial responsibilities. Utilizing technology to verify eligibility automatically decreases the chance of human error, while providing faster results ( Zannetti).” Implementing new billing system/software along with a high quality EMR system will help maintain registration, prior authorization, and claims as a smooth process. When we have a system in place that lets the patient know if they have any outstanding balances, collecting payment prior to services will help decrease the number of uncollected payments from patients. with bringing on modern technology and EMR software that would allow for multiple facilities and providers to share information between the care team would help provide smooth care, manage medical history, follow claims, denials, and know the transfer of care between facilities. “ By selecting a robust EMR that allows an agency to properly setup billing holds, eligible claims can be easily identified and sent out immediately when ready. Partnering with a vendor that assists with electronic document management is also essential in reducing the time it takes to receive these required documents (Zannetti).” Bringing in modern technology and software’s will only better the workflow for the facility, minimize human error, provide red flags for errors, and will also help guide providers in selecting proper coding for billing. Recommendations

17 “ Revenue integrity is a top priority for healthcare leaders, CFOs, and revenue cycle management executives. Revenue integrity as an enterprise function is evolving into a broader concept of charge capture, acuity documentation, and quality achievement all culminating in reimbursement performance. This function should evolve with market dynamics, including the growth of hospital-employed physicians, technological advancements with electronic health records, value-based payment models, analytics and the constantly shifting regulatory environment. Healthcare organizations should not only develop and revenue integrity program but also ensure it evolves in step with the evolution of healthcare markets, driven by dynamic factors such as regulatory changes, mergers and acquisitions and advances in healthcare technology. Traditional revenue integrity programs have focused on hospital charges that have a high revenue yield (HFMA, 2019).” As we interview and recruit for the position of someone in RCM, the main qualifications/skills one must have been basic computer knowledge, customer service, communication, flexibility, willingness to train, adaptive learner, and be a collaborator. One of the important roles from management is to make sure all staff is up to date on their competencies, and if there is any recent changes, materials or training needed this should be provided and organized by the management team. A great management team will always work on being knowledgeable on changes, new requirements, training material, and any necessary urgent changes needed. A good leader is to make sure they lead their team in the right direction and provide all necessary information for the team to be able to complete their job to the best of their abilities. As daily operations change and there is always moving pieces daily in the back- end processes, leadership needs to make sure they ensure everyone is informed and trained adequately.

18 As stated by The Midland Group “Revenue Cycle Management teams should include individuals with financial and clinical backgrounds, to best understand impact on the hospital. Every member of the team must come with the attitude that they can be effective in the revenue cycle by performing their job to the best of their ability. Each team member should see the group as a collaborative effort to increase revenue and decrease errors. Two of the most important skills you should look for when hiring RCM team members is efficiency and resourcefulness. The answers will not always be obvious so team members must be able to conduct research and make decisions based on their findings. It is also important that team members have some level of aptitude with technology.” When we begin to discuss the errors in cash flow or revenue in general, we know that the first step is always making sure that at the patient registration and demographics section everything must be entered correctly. Verifying the patient’s name, DOB, address, social, insurance and anyone who they would like to discuss their medical records with. If the patient information or insurance is entered incorrectly this will cause a ripple effect of incorrect information in the medical record, claim rejection, reimbursement amount may be less, or if the grace period is past for resubmitting the claim this could result in complete rejection of the claim. There are other back-end process revenue cycle errors such as failure in getting a prior authorization, wrong CPT code, wrong diagnosis code, will all result in denied claims. With any denied claims this will affect the cash flow to the organization as they are relying on payment from the insurance company for the services rendered. The delay in payment from insurance companies for the services rendered impacts the facility negatively as they are unable to pay their providers and other bills necessary to keep the organization afloat.

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19 As we know in the back end process the team has a lot of moving pieces and must be up to date and speed with multiple changes. The concerns with constant moving pieces and speed are mistakes in processing claims, miscommunication, no communication between front and back- end teams, poor training, and staff shortages. Everyone makes mistakes as do computers, but human error chances are higher than the electronical system which would catch errors and flag the system. By minimizing errors, we need to make sure proper training has been provided and continues to be provided. We have covered the prevention roles of making sure competencies, training, communication, and great leadership will help us minimize the gaps in the process. As we discuss how to minimize errors and create a better workflow would be to make sure we provide the best possible training. One major step we can take is making sure that we have an EMR system that has hard stopped, when it recognizes an error or that information does not match what the insurance carrier has the patient registered as. The next steps in place would be providing proper training that would spend considerable time per category to make sure the information and importance of understanding to enter all information correctly. Providing discussion and one on one with the importance of entering insurance and demographics correctly. Making sure all information is spelled correctly and asking question along the way if you do not understand something. Once the training classes have been provided, we can have protocols in place that would have the front-end team do their checks and balances. One of the protocols that is in place is while making the appointment we verify all information; demographics, DOB, social security,

20 insurance, pharmacy, primary care provider, imaging center and even the laboratory they prefer to use. Each of these things would be verified again at arrival at the facility. This ensures that we have the correct information, and the patient would also verify all the information. As previously mentioned with the EMR system this would help the providers also with making sure the correct diagnosis codes are entered, CPT, and HCPCS codes as well. Making sure all the checks are done across the board minimizes denials. Minimizing paper communication, increase the use of electronic communication with insurance companies, pharmacies, and other care plan teams. “Computerized provider order entry (CPOE) is a method that allows physicians and other providers to order services for a patient via a computerized system instead of the paper ordering system used historically. CPOE is used in both inpatient and outpatient settings. In the inpatient and ambulatory surgery and emergency department settings, CPOE allows for consistent and efficient communication between the provider, nursing and ancillary departments, and the pharmacy. In outpatient clinic and physician practice settings CPOE allows for ease of communicating most prescriptions to pharmacies. CPOE has several advantages over paper orders: • Reduce errors and improve patient safety: At a minimum, CPOE can help organizations reduce errors by ensuring providers produce standardized, legible, and complete orders. In addition, CPOE technology often includes built-in clinical decision support tools that can automatically check for drug interactions, medication allergies, and other potential problems. • Improve efficiency: By enabling providers to submit orders electronically, CPOE can help organizations get medication, laboratory, and radiology orders to pharmacies, laboratories, and radiology facilities faster, saving time and improving efficiency.

21 • Improve reimbursements: Some orders require preapprovals from insurance plans. CPOE, when integrated with an electronic practice management system, can flag orders that require preapproval, helping organizations reduce denied insurance claims. (Healthit.gov 2018) (Casto, 2021).”

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22 References AAMC. (2023). Strategic planning. https://www.aamc.org/career-development/affinitygroups/gip/strategic-planning Advantum Health. (2022). What is revenue integrity and why is it important for providers? Advantum Health. https://www.advantumhealth.com/what-is-revenue-integrity-and-whyis-it-important-for- providers/ Casto, A. B. (2021). Principles of Healthcare Reimbursement (7th ed.) [E-book]. AHIMA. Centers for Medicare and Medicaid Services. (2021). Other administrative simplification rules. HHS. https://www.hhs.gov/hipaa/for-professionals/other-administration-simplificationrules/index.html Condon, K. (2017). How to hire successful RCM team members. The Midland Group. https://www.midlandgroup.com/blog/how-to-hire-successful-rcm-team-members/ Copeland, Lindsey New Study Finds that Private plans Pay Hospitals More Than Medicare for Inpatient and Outpatient Services retrieved from https://www.medicarerights.org/medicare-watch/2022/05/19/new-study-finds-that-private-plans- pay-hospitals-more-than-medicare-for-inpatient-and-outpatient-services 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- success Fact Sheet: Majority of Hospital Payments Depend on Medicare or Medicaid; Congress Continues to Cut Hospital Reimbursement for Medicare retrieved from https://www.aha.org/fact-sheets/2022-05-25-fact-sheet-majority-hospital-payments-

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23 dependent-medicare-or-medicaid#:~:text=The%20Medicare%20Payment%20Advisory %20Commission,from%20%2476%20billion%20in%202019 . NHE Fact Sheet retrieved from https://www.cms.gov/data-research/statistics-trends-and- reports/national-health-expenditure-data/nhe-fact-sheet Friedberg, M., Chen, P., Simmons, M., Sherry, T., Mendel, P., Raaen, L., Ryan, J., Orr, P., Vargo, C., Carlasare, L., Botts, C., & Blake, K. (2020). Effects of Health Care Payment Models on Physician Practice in the United States https://doi.org/10.7249/rr2667 Gaille, L. (2017). 12 advantages and disadvantages of managed care. Ittana. https://vittana.org/12- advantages-and-disadvantages-of-managed-care HIPAA retrieved from https://www.hipaajournal.com/ HFMA , 2019 Revenue integrity: an evolving function for hospitals and health systems retrieved from https://www.hfma.org/legal-and-regulatory-compliance/revenue-integrity-an-evolving- function-for-hospitals-and-health-2/ iPatientCare. (2018, April 6). Patient’s fiscal responsibility is equally important as Patient Care. Retrieved July 17, 2022, from https://ipatientcare.com/blog/patients-financialresponsibility-is- equally-important-as-patient-care/ Informed Consent retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430827/#:~:text=Informed %20consent%20is%20the%20process,undergo%20the%20procedure%20or%20intervention . Kay, G. (2019). The 9 steps of healthcare revenue cycle management are explained. PMMC. https://blog.pmmconline.com/blog/revenue-cycle-management-explained

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24 Koleva-Kolarova, R., Buchanan, J., Vellekoop, H., Huygens, S., Versteegh, M., Mölken, M. R., Szilberhorn, L., Zelei, T., Nagy, B., Wordsworth, S., & Tsiachristas, A. (2022). Financing and reimbursement models for personalized medicine: A systematic review to identify current models and future options retrieved from https://doi.org/10.1007/s40258-021-00714-9 Land, T. 2021 The Bottom Line: Strategy Drives Financial Growth in Healthcare retrieved from https://pubmed.ncbi.nlm.nih.gov/34813510/ Medical Billers and Coders. (2015). Pros and cons of various payment models and their effect on practices. https://www.medicalbillersandcoders.com/articles/practiceadministration/pros-and- cons-of-various-payment-models-and-their-effect-onpractices.html Navigant, N. (2022). Revenue integrity: An evolving function for hospitals and health systems. HFMA. https://www.hfma.org/legal-and-regulatory-compliance/revenue-integrity-anevolving-function- for-hospitals-and-health-2/ Pract, J.O., 2009 Strategic Planning: Why it makes a difference, and how to do it retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2790676/ Rosen, M. J., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D. R., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433–450. https://doi.org/10.1037/amp0000298 What is revenue cycle management in healthcare? Retrieved from https://www.pathstonepartners.com/blog/what-is-revenue-cycle-management-and-why-is-it- important/#:~:text=Improved%20Patient%20Satisfaction%3A%20Revenue%20Cycle,forms %20for%20tracking%20patient%20data .

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25 The Centers for Medicare and Medicaid Services. (2021). Mandatory insurer reporting (NGHP). CMS. https://www.cms.gov/Medicare/Coordination-of-Benefits-andRecovery/Mandatory-Insurer- Reporting-For-Non-Group-Health-Plans/Overview Zannetti, M. Transforming Revenue Cycle through Technology? Retrieved from https://www.healthtechmagazines.com/transforming-revenue-cycle-through-technology/

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IHP 6309-1 Final Project Sepaker Notes

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