Final Project Submission White Paper

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Southern New Hampshire University *

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Health Science

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Apr 3, 2024

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1 Kelly Gray Southern New Hampshire University Healthcare Reimbursement Final Project Submission: White Paper February 23, 2024

2 Table of Contents 1. Reimbursement and The Revenue Cycle ……………………………………… 4 Reimbursement……………………………………………………………….4 Flow of Patient…………………………………………………………………4 2. Departmental Impact on Reimbursement……………………………………..5 Departments………………………………………………………………………….5 Activities…………………………………………………………………………….7 Responsible Departments………………………………………………………………7 3. Billing and Reimbursement ……………………………………………………….7 Third Party Policies………………………………………………………………..8 Key Areas of Review………………………………………………………………..8-9 Structure…………………………………………………………………………………9 Plan………………………………………………………………………………….9-10 4. Marketing and Reimbursement …………………………………………………….10 Contracts………………………………………………………………………….10

3 Compliance………………………………………………………………………….10 5. Resources……………………………………………………………………………..12 Introduction Most people understand general knowledge of how the reimbursement process works. It is compensation of certain expenses for offerings that were paid for already. An example is purchasing a lunch for your fellow co-worker, who would return the money for the lunch that you just previously paid for, but for the healthcare field, that meaning is a little more complicated and the indebtment is much larger than just a co-worker buying lunch for another co-worker and being returned the money. In most cases, it isn't the patient that is looking to be reimbursed, it is usually the healthcare organization, or government/state agencies that file the claims and want to

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4 be reimbursed. This white paper will deliberate on how important billing and reimbursement, the revenue cycle, and the departmental area affects the healthcare facility at the Sunshine Valley Hospital. (Fictional Hospital) 1. Reimbursement and The Revenue Cycle: a. Reimbursement: Most people understand what reimbursement means. It is the initiative to repay someone who has spent their own money on products or services and is looking to be compensated for that. Within the healthcare field, reimbursement is extremely important in order for a health facility to be successful. Most of Sunshine Valley’s revenue is received from medical claims and the reimbursement from them. If patients receive treatment and there is no repayment, the healthcare organization’s growth can be overall hindered. When it comes to healthcare, clinics, hospitals, doctors, and certain medical organizations they have to pursue reimbursement for the amenities that were already provided to patients. b. Flow of patient: From the Beginning, the administrative part here at Sunshine Valley starts off with scheduling outpatient and inpatient services, making sure a patient’s insurance is valid, and registering the patient. These duties come with verifying information from the payers, making sure the patient’s information is correct, and

5 making sure the requirements are being met for the paying insurance company. The mid-way process includes a hard-soft coating, capturing charge, and managing our cases. The services we provide usually happen around this time frame. It is the principle that all of our patients' information is coded the right way so that billing goes smoothly. The very end of the billing part is what truly affects reimbursement. This is called the back-side. This is where denied claims, processing bills, posting payments, correcting claims, and providing additional documents would transpire. All of these correlate together to make the reimbursement process at healthcare facilities a lot easier. All of these steps are needed for our hospital and our providers to be properly reimbursed. 2. Departmental Impact on Reimbursement a. Departments: Inside every category of the revenue cycle, every department has certain duties that have to be carried out in order to support circulation of the RCM. When appointments are made by a patient, and they are pursuing medical services, the healthcare revenue sequence management starts and it stops when claims and payments from the patients have been made. When patients make appointments, the administrative assistant here at our facility will do the scheduling, verify insurance to see if a patient is eligible, and to establish an account. Making a patient account and registering them details coverage from insurance, their medical history, and making sure we are following healthcare revenue sequence processes. From our perspective, making sure a patient's information is

6 accurate from the beginning starts with scheduling and making sure our patients are registered into our system properly. This makes sure that everything is in order so that claims can be received and be billed in the most effective way possible. Usually starts with the patient's demographics like their name, how old they are, their birthdate, where they work, their home address, the insurance provider that they go through, and the patient's social security number. Staff should ask our patients for proper identification such as their drivers license, or identification card. The middle revenue management cycle includes the front office where the administrative assistant works and the provider. Our front office has to make sure that everything is in order so that claims can be received and be billed in the most effective way possible. The last thing the insurance company wants to deal with is kickback from a claim and then having to do all kinds of extra work to get the claim corrected. After the patient is seen and taken care of, a claim can finally be submitted. The coder here at Sunshine Valley has to recognize the kind of treatments that the patient has received along with the right codes. This is how our organization determines how much we will receive from reimbursement. The financial part of it all is pretty much supervised by the health information management team. (HIM) Our personnel help figure out the proper codes that are needed to process claims. If compensation isn’t managed properly, collection rates can lower, billing costs can become costly, and accounts receivable can dramatically decrease. The value of care then lowers dramatically. Auditing is a very important process that authorizes our organization to gain access to the issue and the repair of any irregularities. Here at Sunshine Valley we do inspections of our procedures done by HIM when it comes to reimbursements to help improve our revenue production and to make sure consumers are protected from prices

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7 that are not reasonable. When our accounting information is updated regularly, it’s a lot easier to spot mistakes in the reimbursement process. At the end of our revenue cycle, HIM and our administrative assistants oversee our financial services, they help with processing bills, they post the payments, and they redo the claims that have been denied due to clerical errors. b. Activities: There is plenty of data that has to be looked over to see if changes need to be made, and to differentiate all of the payments that were due within a 30 day radius, with what has accumulated at the end of the 30 days. There are a few different data sets but the number of denied claims on a month to month basis to see if changes have been made to lower the amount. c. Responsible Department: Medical coding and billing is a complicated task that requires everyone here at Sunshine Valley Hospital to play their part so that patients are billed properly for their services that they receive. The administrative assistant here is responsible for the correct patient registration, and insurance information, and our billing department is responsible for making sure that our facility complies with government and state coding policies. 3. Billing and Reimbursement: a. Third Party Policies:

8 Making sure that our staff members comply with the standard regulations, policies, and law is called the Periodic Review of Procedures. If a compliance plan is to be functional, there have to be procedures that are set in stone. An ethical code of conduct, and guidelines that have to be put into effect. Sunshine Valley Hospital relies on reimbursements heavily through third party payers like government, state, and federal agencies, along with insurance companies. It is very important that PFS personnel follow stern guidelines when regulating payer- mix for precision and for the largest reimbursement. The best way is to place an independent compliance committee in charge. That would be a great way to make sure we were enforcing the proper procedures and the code of conduct. b. Key Areas of Review: Maximization and being timely is one of the key areas for review here at Sunshine Valley Hospital when it comes to receiving reimbursement for third party payers. It starts off with collecting all of the patients demographics in the registration stage and that's usually first. Our receptionists will make sure that deductibles, details of our patient’s insurance, and co-pays are correct. When documenting information that pertains to a patient's procedures and their treatments, they have to be documented correctly because this provides a standard for the processing of claims. The reason for this is because when incorrect information is used to file a claim, it’s usually because the wrong codes were being used. It spares the long process of the patient’s claims being denied or delayed. The next stage is a patient’s demographics being verified using certain eligibility tools. This also

9 makes sure that information is accurate so that claims don't get denied or delayed. Our staff has to be sure all of the codes are going through the clearinghouse without error. Our staff follows up on the claims and they make sure that they pay attention to the process of reimbursement because they are the ones who make sure our organization is properly paid all of our recompense from either the patients, the government, or a private payer. Training sessions are often organized so staff can stay fully updated on better ways to perform their jobs. There are new great things that are evolving everyday including technology that can help our staff recognize the tasks in their positions better. Our staff is also properly monitored to ensure the cycle of all claims is moving efficiently, making sure that all of the accounts are updated in order to have the correct information at all times so that they know the important steps that need to be taken if otherwise. c. Structure: The follow up for structuring our staff is extremely important. We have to make sure that RMC’s procedure operates in a timely fashion and with effectiveness. We can do this by giving our staff training on present and updated procedures and policies. To make sure that this is efficient, our staff members will be submitted to mock proctored reviews. d. Plan: The plan here at Sunshine Valley Hospital is to make sure all of our staff members are within compliance of the procedures. It will involve several elements. The first element would be under review. The second element would be a quarterly review of the claims that are either rejected or

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10 pending. The third element would be an audit every month of the claims that were paid that show any digression of payments that were not paid. The final element would be individual staff evaluations of their performance between the supervisor and the staff. 4. Marketing and Reimbursement: a. Contracts: When coming to an agreement with a third party payer about managed care in a facility comes with training, teamwork, and preparing the staff. When new contracts are resolved, revenue can be further increased due to it being easily accessible. This can help improve the reimbursement for the entire healthcare system. b. Compliance: There are tons of agencies that have provided direction including specific laws to healthcare facilities that make certain of coding compliance and ethical billing. One of the federal agencies that gives healthcare organizations guidance is The Office of Inspector General. They help with suggestions when it comes to code of conduct and third party billing. If a healthcare facility didn't have these resources, it could have a terrible impact on a healthcare facility. The repercussions of non-compliance with regulations and ethical standards can be very risky for a healthcare organization.

11 Resources

12 Manley, R., & Satiani, B. (2009). Revenue cycle management. Journal of Vascular Surgery , 50 (5), 1232–1238. https://doi.org/10.1016/j.jvs.2009.07.065 Torrey, T. (2024, February 22). What is healthcare reimbursement? Verywell Health. https://www.verywellhealth.com/reimbursement-2615205 Ahmed, T. (2023, September 20). Revenue Cycle Management (RCM): The healthcare financial guide you need (2024) - Streamline Health . Streamline Health. https://streamlinehealth.net/revenue-cycle-management-healthcare/ Reimbursement and Revenue Cycle in healthcare - 1089 words | Research paper example . (2023b, February 20). IvyPanda. https://ivypanda.com/essays/reimbursement- and-revenue-cycle-in-healthcare/#:~:text=Departmental%20Impact%20on %20Reimbursement,institutions%20due%20to%20inappropriate%20information . Young, S. (2022, December 6). Healthcare Process improvement: 6 strategies. Health Catalyst . https://www.healthcatalyst.com/insights/healthcare-process-improvement-6- strategies What is Healthcare Billing . (n.d.). https://www.enter.health/post/what-is-healthcare-billing Lambert, D. (2023, June 2). Healthcare 101: How healthcare reimbursement works? Continuum. https://www.carecloud.com/continuum/how-healthcare-reimbursement- works/ KMC University. (2022, September 7). What is a Third-Party Payer in Healthcare? | KMC University . https://kmcuniversity.com/what-third-party-payer-healthcare/

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13 Good, K. (2019, April 3). Three crucial steps to maximize your reimbursements . HealthPro Medical Billing. https://healthpromedical.com/reimbursement/three-crucial- steps-to-maximize-your-reimbursements/ Healthcare Compliance: All You Need To Know | symplr . (n.d.). https://www.symplr.com/blog/healthcare-compliance-all-you-need-to-know What is the importance of good ethical standards in health organizations? (2020, October 20). Small Business - Chron.com. https://smallbusiness.chron.com/importance- good-ethical-standards-health-organizations-15449.html

Final Project Submission White Paper

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