Assessment 2.edited (2)

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Capella University *

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5006

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Health Science

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Dec 6, 2023

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1 Revenue Cycle Beth Doeden Capella University MHA-FPX5006 Hlth Care Fin & Reimbursement June 27, 2022

2 Revenue Cycle Proposal After reviewing the organization's finances and billing workflows, it has come to light that a new billing process is needed to standardize workflows and help the organization become more efficient. Though these changes may be challenging, it is for the benefit of patients and physicians. Financial Strategies Choosing a payment management system is essential for streamline eligibility, prior authorizations, and payment workflows. Patients will be expected to provide insurance information before their scheduled appointment. They will be informed, before care, what their coverage will be and if they have copays (AMA, 2022). Then, they will have an opportunity to plan for any additional expenses they may encounter in their care and there will not be any surprise fees they cannot pay. Patients will also be encouraged to pay for their services before their visit. The payment management system will have the capability to scrub the claims submitted through insurance to help reduce the number of errors in the submission and identify where updates need to be made before the claim submits to insurance (AMA, 2022). This will aid in the reduction of denials and obtain reimbursement promptly. Electronic payment options will be available and suggested to patients for remittance. Paper forms of payment hold a higher risk because they are easily lost, are susceptible to forgery, and take more time for remittance. Patients will have the ability to make payments directly on the website and have the option of payment plans that include directly withdrawing payments out of a checking or savings account. In addition, patients will have the opportunity to receive an

3 electronic statement rather than a paper statement. Paper statements can be lost in the mail or within the home (AMA, 2022.). The reimbursement will be based on reimbursement rates as determined by the fee schedules set forth by CMS, and all providers will be Medicare and Medicaid providers. The organization will adopt the standard use of ICD10, CPT, NDC, and HCPC codes to streamline the charges coming through the payment management system. These costs may be reduced if the patient pays cash upfront before a visit or procedure. If the need to purchase capital equipment, such as imaging equipment, pricing may be temporarily increased until the equipment payments are complete (CMS, n.d.). Contract Negotiations There are many things to consider when negotiating contracts with payors. There is more to consider than just being paid. Provider obligations need to be understood and fair. State laws must be abided by. They must ensure they will conform to using or accept standard codes set by CMS for charging. In addition, they must ensure that there is an understanding of the process in place in the event of policy changes and what influence our providers will have on those changes (Verno, 2005). We will be working with national and regional payors. We are a large healthcare organization, and with the demographic we see, national makes the most sense for reimbursement and staying ahead in healthcare. Regional makes sense when there are unique needs in our demographic. Local/Hospital comes with too much risk, which could lead to loss of revenue (Proctor, 2021). Charity Care

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4 Patients who do not have insurance or have insurance and cannot pay for their hospital or emergency services may be eligible for Charity Care. Patients who do not have insurance will be required to file for government and state assistance to help cover some or all of the costs. If a balance remains, they will qualify for Charity Care. If patients have insurance but not the ability to pay, they will have the opportunity to fill out an application for Charity Care. If they meet the financial requirements based on income and family size, they may have their entire balance paid. To offset this cost, Medicare and the Internal Revenue Code can make payments to qualifying hospitals and follow the Medicare guidelines associated with the reimbursement (Villagrana et al, 2018). Benefits The benefit of using this standardized practice not only streamlines workflows for providers but also makes it possible for coders to submit claims and receive reimbursement promptly. Patients are given upfront costs so there are no surprises, and they have the ability to plan for repayment or apply for additional aid (Wilson, 2021). Working with Charity Care will help cover expenses for those who cannot pay and receive the critical care they need. The process of electronic submission of claims saves on time and cost for the organization along with electronic patient payment. With this proposal, we will increase our revenue by standardizing processes and streamlining our workflows, receiving claims faster, and helping prevent nonpayment for services.

5 References: Code Set Basics. (n.d.) CMS.Org. Retrieved June 6, 2022, from Code Sets Basics (cms.gov) Proctor, N. (2021). Do You Know the 5 Categories Of Payors and Their Respective Roles and Drivers? Cel for Pharma. Do you know the 5 categories of payers and their respective roles and drivers? | CELforPharma Revenue Cycle Management; Streamline and Automate Your Practice's Revenue Cycle. (2022). AMA. Retrieved June 6, 2022, from Revenue Cycle Management | Workflow and Process | AMA STEPS Forward | AMA Ed Hub (ama-assn.org) Verno, S. (2005). Negotiating Health Insurance Contracts. American Academy of Professional Coders. Negotiating Health Insurance Contracts - Codify by AAPC Villagrana, M., Liu, E., Crandall-Hollick, M. & Hughes, J. (2018). Hospital Charity Care and Related Reporting Requirements Under Medicare and the Internal Revenue Code. Congressional Research Serivces. Hospital Charity Care and Related Reporting Requirements Under Medicare and the Internal Revenue Code (fas.org)

6 Wilson, J. (2021). Measuring the Effectiveness of Revenue Cycle Management in Healthcare. Sybrid. Measuring The Effectiveness Of Revenue Cycle Management In Healthcare - Sybrid MD

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Assessment 2.edited (2)

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