Strategies for Successful Healthcare Finances & Reimbursement

9-1 FINAL PROJECT Nikkia Bates Southern New Hampshire University IHP-630-Q1493 Healthcare Fin & Reimbursement Prof. Rebecca Arsenault November 15, 2023

Introduction ■ My name is Nikkia Bates, a healthcare consultant who specializes in internal and external on-boarding success of new team members. ■ In Today's presentation, I will be providing strategies and techniques that assist in improving the organization's success in: – Stategic Planning – Revenue Cycle Process – Reimbursement compliance processes

What is Strategic Planning? ■ Strategic planning is the process of organization leaders defining their visions for the future and identifying their organization's goals and objectives (Bigelow, 2022). – Strategic planning gives organization's the opportunity to track its goals and objectives. – Benefits of strategic planning include; the organization being pro-active, operation efficiency, enhanced profitability

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Financial Managem ent Principles ■ Financial management principles can be utilized to inform and enhance the healthcare organization's strategic planning process as a whole. ■ There are several financial management principles methods healthcare organizations utilize to improve their strategic planning: – Setting specific monetary objectives – Predicting future income and spending – Evaluating prior financial results – Implementing cost-saving strategies – Benchmarking

Collaborative Teamwork Integration ■ Collaborative teamwork encourages the group to combine expertise and problem-solve together, while also assigning individual tasks and roles for autonomy (Indeed, 2023). ■ Collaborative teamwork can help the revenue–cycle process by setting measurable goals for each cycle within the process. For example reducing medical coding errors in the back-end process, or reducing patient demographic input errors in the front-end process. ■ Strategies for Collaborative Teamwork Integration: – Ensuring all team members are aware of the mission, vision, goals and objectives of the organization – Specify each team members role, task, and responsibilities – Encourage open communication amongst team members – Implement annual meetings to review the organizations progress and to identify any issues within the organization

Collaborative Teamwork Integration Continued. ■ Benefits of Collaborative Teamwork Integration: – Increases productivity and efficiency – Common goals – Increases diversity – Enables learning

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Staffing Impact ■ Hiring and on-boarding the correct candidate for a position based on experience, skills, and education is vital to revenue cycle outcomes and the overall teams performance. ■ Healthcare organizations can utilize talent acquisition members who will source, attract, and interview employees that are knowledgeable and hold skills of the front, middle, and back-end billing process (SHRM, 2022). ■ The front-end, middle, and back-end workflows have a lot of room for basic human error. – Front end revenue cycle errors are about 24% of all errors – 12% of claim denials are from mid- cycle processes – Denials for the back end of the revenue cycle account for 15%

Staffing Impact Continued. ■ Front-end revenue cycle process is considered the "face" of the healthcare organization. When a patient seeks medical services, their first encounter would be with the "front-end" staff. ■ Middle-end revenue cycle process consists of staff conducting clinical documentation, case management, charge processing, and coding. ■ The back-end revenue cycle process consists of staff collecting patient payments after healthcare services have been rendered (Enter Health, 2023).

Healthcare Reimbursement ■ Two Primary Healthcare Reimbursement Types – Government Insurance Reimbursement – Private Insurance Payers or Third- Party Payers ■ Two Primary Healthcare Reimbursement Systems – Fee-for-fee services – Value-based systems

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Improvem ent Processe s ■ There are three "principles" a healthcare organization should utilize in order to improve overall reimbursements for the various stakeholders within the revenue cycle process. – Pre-Registration Rate – Service Authorization Rate – Amount of days in Accounts Receivables

Advantage s and Disadvanta ges of Two Different Payer Models ■ Private Health Insurance include: – Cigna – Blue Cross Blue Sheild – Aetna ■ Government Health Insurance Include: – Medicare – Medicaid ■ Advantages of Private Health Insurance – Providers receive a higher reimbursement payment rate – Flexibility of negotiation

Advantage s and Disadvanta ges of Two Differe nt Payer Models Continued. ■ Dis-advantages of Private Health Insurance – Pay greater reimbursement rates than government-supported insurance companies. ■ Advantages of Government Health Insurance – Increase in the demand of medical services – Increase of "fixed payments" ■ Dis-Advantages of Government Health Insurance – Lower amount of those “fixed payments” being reimbursed to healthcare administrators

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Advantage s and Disadvanta ges of Managed Care Plans ■ Managed Care Plans consist of three different plans: – Preferred Provider Organization (PPO) – Health Maintenance Organization (HMO) – Point of Sale Care ■ Advantages of Managed Care Plans – It lowers the costs of health care for those who have access – People can seek out care from within their network – Information moves rapidly within a network ■ Disadvantages of Managed Care Plans – It limits care access for those who do not have insurance or provider coverage. – The rules of managed care are extremely strict – People are forced to advocate for themselves

Revenue-Cycle Process The revenue cycle is the flow, management, collection, and capture of the organizations revenue. The revenue-cycle process is complex, healthcare organizations must understand the various models and methods that can be utilized to improve the revenue-cycle processes. The Integrated model combines both the financial and administrative processes involved in healthcare revenue cycle management (RCM) such as: Patient registration Scheduling Coding Billing Claims Management Payment Processing

Workflow Assessme nt Findings REVENUE INTEGRITY CAN BE DEFINED AS THE PRACTICE OF TRANSLATING PATIENT EXPERIENCES TO REVENUE IN A HEALTHCARE ORGANIZATION AND AVOIDING REVENUE LEAKAGE AND COMPLIANCE ISSUES COLLECTING PATIENT FINANCIAL RESPONSIBILITY PAYMENTS IN THE FRONT-END PROCESS STANDARDIZING PROCEDURES ACROSS THE FRONT, MIDDLE, AND BACK-END REVENUE CYCLE PROCESS ANNUAL AUDITS AND REVIEWS TECHNOLOGY TRAINING OR SKILL-BUILDING COURSES

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Reimbursem ent Compliance ■ Federal Regulation: The Hospital Readmissions Reduction Program (HRRP) – A Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. – Negative impact of hospital readmission result in a lower reimbursement to the organization. ■ State Regulation: Medicaid – Positive impact of Medicaid is providing healthcare coverage to low-income individuals. – Negative Impact of Medicaid is reimbursements are known to be on the lower end of healthcare reimbursement cost ■ Third-Party Unique Regulatory: The Prompt Payment Act of 1982 – Positive impacts of this act requires federal agencies to pay their bills on a timely basis, to healthcare organizations. – Negative impacts consist of bills not being paid in that “promptly time frame,” which causes reimbursement to be delayed.

Reimbursem ent Compliance: Reporting Requiremen ts ■ Providers are required to meet quality performance standards. – For Medicare a quality measure reporting system is used to determine the standards have been met. – Providers must fill out and submit a yearly Medicare Cost Report on the services provided throughout the year. – Healthcare organizations are required by both Medicare and Medicaid to report all over and under payments within 60 days.

Technology and System Impacts ■ Implementing Electronic Health Records EHR''s that assist with front, middle, and back-end process will have positive impacts. ■ Implementing Electronic Health Records EHR's with artificial intelligence will assist in improving and detecting any issues within the revenue cycle. ■ Automation of insurance eligibility and verification, charge entry, charge capture, payment posting, and claim submission will assist with prior authorization and avoidance of claim denial. ■ Patient portals.

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Recommendations Healthcare organization leaders should recruit employees that are knowledgeable of revenue cycle process workflows. Training seminars and monthly meetings with healthcare organization leaders. Implement Electronic Health Records EHR, that are manageable throughout the different processes in the revenue cycle.

References ■ Administrator, S. (2020, June 12). 6 key laws that regulate the healthcare industry? Law Offices of Art Kalantar. https://www.kalantar.law/laws-that-regulate-healthcare-industry/ ■ Bigelow, S. J., & Pratt, M. K. (2022, March 30). What is strategic planning? definition and steps - techtarget . CIO. https://www.techtarget.com/searchcio/definition/strategic-planning ■ Blog, P. (2023, March 16). 6 tips for negotiating insurance contract rates - providers take note! Medical billing and collections are as low as 1.99%. https://practiceforces.com/blog/6-tips-for-negotiating-insurance-contract-rates-providers-take-note/# :~:text=By%20initiating%20a%20rate%20change,negotiate%20the%20insurance%20contract%20r ates ■ Brianevans. (2023, March 22). How your healthcare system can overcome the two most common payment processing challenges . HealthPay24. https://www.healthpay24.com/blog/health-payment-systems ■ Casto, A. B. (2018). Principles of healthcare reimbursement (6th ed.) Chicago, IL: American Health Information Management Association. ■ Corporation, M. (n.d.). What is financial management: Dynamics 365 finance . What is Financial Management | Dynamics 365 Finance. https://dynamics.microsoft.com/en-us/finance/what-is-financial-management/#:~:text=The%20defin ition%20of%20financial%20management,to%20achieve%20your%20business%20goals . ■ Gaille, L. (2017, June 15). 12 advantages and disadvantages of managed care . Vittana.org. https://vittana.org/12-advantages-and-disadvantages-of-managed-care ■ Hughes, S. (2020, March 5). Pros and cons of Universal Healthcare AKA Medicare for all. Coronis. https://www.coronishealth.com/blog/pros-and-cons-of-universal-healthcare-aka-medicare-for-all/ ■ Integrated revenue cycle (IRC) - RCM glossary: Md clarity . RCM Glossary | MD Clarity. (n.d.). https://www.mdclarity.com/glossary/integrated-revenue-cycle-irc

References Continued. ■ Julian, A. (2023, June 16). 6 areas of your revenue cycle that can be maximized with digital transformation . Armanino LLP. https://www.armanino.com/articles/healthcare-revenue-cycle-maximized-with-digital-transformation/ ■ LaPointe, J. (2018, March 14). 4 keyways to improve healthcare revenue cycle management . RevCycleIntelligence. https://revcycleintelligence.com/news/4-key-ways-to-improve-healthcare-revenue-cycle-management ■ Lopez, E., Neuman, T., Jacobson, G., & Levitt, L. (2020, April 15). How much more than Medicare do private insurers pay? A review of the literature. KFF. https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-li terature/ ■ Moneypenny, M. (2019, March 25). How to prevent claim denials during every phase of the revenue cycle . Etactics. https://etactics.com/blog/prevent-claim-denials ■ Revenue Cycle Management (RCM): The Healthcare Financial Guide You Need (2023) . Streamline Health. (2023, September 20). https://streamlinehealth.net/revenue-cycle-management-healthcare/ ■ Revenue integrity and healthcare: Prevent revenue leakage (2023) . Streamline Health. (2023, October 4). https://streamlinehealth.net/revenue-integrity-healthcare/ ■ SHRM. (2022, July 27). Talent acquisition . SHRM. https://www.shrm.org/resourcesandtools/tools-and-samples/hr-glossary/pages/talent-acquisition.aspx ■ Teamwork and collaboration: How to improve both at work - indeed. (2023, February 27). https://www.indeed.com/career-advice/career-development/teamwork-and-collaboration ■ The difference between healthcare payers and Providers . Panoramic Health. (2023, May 31). https://panoramichealth.com/blog/the-difference-between-healthcare-payers-and-providers/ ■ Tony, P. 2021, July 16). A/R days . Revenue Cycle Report. https://revenuecyclereport.com/ardays/ ■ What’s Medicare? Medicare. (n.d.). https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare

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Healthcare Fin & Reimbursement Final Project

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