Question

III. Billing and Reimbursement A. Analyze the collection of data by patient access personnel and its importance to the billing and collection process. Be sure to address the importance of exceptional customer service. B. Analyze how third-party policies would be used when developing billing guidelines for patient financial services (PFS) personnel and administration when determining the payer mix for maximum reimbursement. C. Organize the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain your rationale on the order. D. Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective? E. Develop a plan for periodic review of procedures to ensure compliance. Include explicit steps for this plan and the feasibility of enacting this plan within this organization. IV. MarketingandReimbursement A. Analyze the strategies used to negotiate new managed care contracts. Support your analysis with research. B. Communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts. Be sure to include the different individuals within the healthcare organization. C. Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete evidence or research. D. Discuss the resources needed to ensure billing and coding compliance with regulations and ethical standards. What would happen if these resources were not obtained? Describe the consequences of noncompliance with regulations and ethical standards. Guidelines for Submission: Your draft must be submitted as a three- to five-page Microsoft Word document with double spacing, 12-point Times New Roman font, one-inch margins, and at least three sources, which should be cited in APA format.

Answer 1

Billing and Reimbursement

1. Analyze the collection ofdata by patient access personnel and its importance to the billing and collection process.

Be sure to address the importance ofexceptional customer service.If the billing and coding system implementation is inaccurate, it would be harmfulto the healthcare practice’s administration. It costs healthcare practitioners over $17 billion formedical coding neglect. About 44% of revenue is not recovered due to unbilled or under-billedclaims.This is why medical billing and coding is so important. Medical procedures ordered andprescriptions used, need to be labeled with a code.Coders have the task of making sure theclaim submitted to the insurance company are coded correctly. Then the medical biller will usethe information from coder to bill the insurance company .

1. Analyze how third-party policies would be used when developing billing guidelines for patient financial services (PFS) personnel and administration when determining the payer mix for maximum reimbursement.

Increasingly, third-party medical billing companies are providing crucial services that could greatly impact the solvency and stability of the Medicare Trust Fund. Health care providers are relying on these billing companies to a greater degree in assisting them in processing claims in accordance with applicable statutes and regulations. Additionally, health care professionals are consulting with billing companies to provide timely and accurate advice with regard to reimbursement matters, as well as overall business decisionmaking. As a result, the OIG considers compliance program guidance to thirdparty medical billing companies particularly important in efforts to combat health care fraud and abuse. Further, because individual billing companies may support a variety of providers with different specialties, we recommend that billing companies coordinate with their provider-clients in establishing compliance responsibilities. Using these 7 basic elements outlined above, the OIG has identified specific areas of third-party medical billing company operations that may prove to be vulnerable to fraud and abuse.

1. Organize thekey areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain your rationale on the order.

There are five areas of importance for timeliness and maximization of reimbursement,they are: Patient access, reduce denials with accurate information, employ eligibilitytools, increase visibility into patient’s responsibility, check patient’s propensity to pay,collect before the instance of care, and financial triage strategies.Patient access can reduce the hospital’s nonpayment risks. This can help preventerrors Proactively correcting errors before claims are submitted, implementing effectiveeligibility tools, gaining visibility into patients’ financial responsibilities, gauging theirpropensity to pay, and capturing at least a portion of patients’ payment up front will helpaccelerate cash flow and reduce accounts receivable (A/R) days outstanding”.

1. Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?

Businesses exist for one simple reason: to solve a big problem. At the core of every great product or service is an unfulfilled need that reaches a big enough market. But it’s not enough to have a great idea that solves a big problem; behind each successful company stands a flexible team that can efficiently turn a vision into a growing business. The 9 tips below will help you organize your team for success.

Management Type: Market Trumps Functional Trumps Matrix.
All organizational structures are evil; but when you have to, align your organization around markets. Aligning employees around markets with a flattened organizational structure increases efficiency, removes gridlock, eliminates conflicting priorities and speeds up the decision-making process in an industry where you’re constantly racing against the clock. (A great example of matrix-style management can be seen when Peter Gibbons messes up his TPS reports in Office Space.)

Empower People to Make Decisions.
Too often, decisions move up the management chain to people who have the least amount of knowledge to make the best decision. Big decisions shouldn’t always be made by management. If you have a smart team, you should empower each person to make decisions that apply to their own groups and roles. In addition to speeding up decisions and helping shape current team members into future managers, this will also instill a sense of ownership throughout your entire team.

Strategic Planning Should Focus on Solutions.
After co-founding several companies, I realized that “strategic planning”–when the management team sits down to figure out where the company should be going–is often a major waste of time and takes the focus away from where your energy should be spent–building a great product. You should be strategically thinking about what problems to solve, not about revenue projections, profits or other forecasts. If you build a great product that solves a big problem, the numbers will follow.

Build Consensus and A Sense of Ownership Through BPT.
The quickest and most efficient way to solve a problem and come up with the best solution is through what I call the Brainstorm Prioritization Technique (BPT). If you have a smart team, they’ll be able to come up with the right answers. BPT will draw out all possible answers, weed out any bad or unfeasible options, build consensus within your team and save time. So how does BPT work? Just follow these five steps:

1. Figure out which team-members should be involved in the brainstorming process based on the problem you’re trying to solve. Try to limit the group to 10; groups that are too big can be difficult to manage.
2. After you’ve assembled the right group of people, clearly state the specific problem you’re trying to solve and allow everyone to shout out possible solutions without taking the time to analyze each option. Write down all the ideas for everyone to see.
3. When you have come up with a good number of possible solutions–anywhere from twenty to 100 ideas–divide the number of possible solutions by three. That will be the number of votes each team-member has.
4. Once everyone has had a chance to analyze the options, the BPT leader should read each idea out loud, take a vote and write the number of votes next to the corresponding ideas. Typically, only a few ideas will receive the most overwhelming number of votes. If more than three or four options garner a lot of votes, eliminate the low scoring options and repeat the BPT.
5. When you have three to four good solutions, research and test each option to figure out which one is most feasible and effective.

Once you’ve completed the BPT, you’ll have achieved the Nirvana of management: knowing which top one or two things to focus on, and consensus around those ideas.

Embrace Self Interest.
In the end, people will always do what’s in their self-interest; rather than fight it, help your employees align their own self-interest with organizational-interests. Allow your team-members to move into new groups and to align themselves with their own self-interests within the company, and reward managers for moving great people out of their groups when they see a better fit.

Forget About Skills When Hiring.
You can always teach skills, but you can’t teach smart. Don’t hire someone based on their current skills; hire people who have raw intelligence and are competitive athletes who will learn quickly on the job. Some of the smartest people I’ve hired have come from schools that don’t show up at the top of any college-ratings list. At the end of the day, the most interesting problems are the ones that nobody’s ever faced before–especially in a startup–so you need to hire people who can think outside the box and come up with unique solutions to complex problems.

Seniority Is Evil.
Hires, fires and promotions should never be determined by seniority; instead, these decisions should only be based on merit. A lot of times you’ll see people who have a sense of entitlement just because they’ve worked somewhere the longest, even though newer members of a team might be the ones coming up with the best ideas or working the hardest. I always tell my team at FindTheBest that I have to earn my job as CEO everyday; if they show that they’re better than me as CEO, then they can have my job.

Don’t Let Customers Dictate the Solution.
When you organize around your market, hence your customer, you’ll be in a better position to see their pain points. Let your customers dictate the problem, but never the solution. Customers sometimes see problems that you don’t because you’re oftentimes too ingrained in the product. When it comes to the solution, however, there’s nobody better (or at least there shouldn’t be anyone better) than your own team to come up with the best answer.

The Most Obvious Solution is Often Overlooked.
As I mention in my book, The Map of Innovation: Creating Something Out of Nothing, it’s the obvious answers that are frequently overlooked. Too often, people aren’t satisfied with obvious solutions, or think that simple solutions can’t be good ones, when in fact they can be the least costly and most effective.

1. Develop a plan for periodic review of procedures to ensure compliance. Includeexplicit steps for this plan and the feasibility of enacting this plan within thisorganization.

Compliance plans reduce the potential for audits, help to prevent false claims, and can aidin the prevention of ethical conflicts (MedPro Group, 2016). According to the Office of InspectorGeneral, Department of Health and Human Services (2017), there are seven fundamental steps toan effective compliance program.Step one is to implement written policies, procedures andstandards of conduct. Step two is designation of a compliance officer (CO) and compliancecommittee (CC) to provide program oversight. Step three is using due diligence in delegation ofauthority. Step four is educating employees and developing effective lines of communication.Step five is conducting internal monitoring and auditing. Step six is enforcing standards throughwell publicized disciplinary guidelines. Step seven is responding promptly to detected offencesand undertaking corrective action. Enacting this plan within the organization will be feasiblewith the appropriate monitoring and delegation of authority to monitor and review theimplementation process.

IV. Marketing and Reimbursement

1. Analyze the strategies used to negotiate new managed care contracts. Support youranalysis with research.

Managed care contracts are an essential part of any sound financial strategy (HealthcareFinancial Management Association, 2017). It is important to consider the payer role duringcontract negotiation. When an organization is preparing to negotiate the type of provider-payerrelationship they desire should be established. This should be done based on whether therelationship is short or long term, and what kinds of interests the organization has. A primary goal for the organization is to receive fair compensation for services, however this is not the soleobjective (Healthcare Financial Management Association, 2017). Organizations must considerthe net changes, rather than specific rates, to negotiate effectively. Other entities, such asancillary providers and physicians must be included into the negotiations so that a robustagreement for the entire organization can be established. An extensive payer profile should becreated prior to negotiations. To effectively create a comprehensive payer profile, these steps canbe followed: reach out to contracting counterpart, mine internal claims data, scrutinize detailsand survey operational staff (Healthcare Financial Management Association, 2017).

1. Communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts. Be sure to include the different individuals within the healthcare organization.

HMO ORGANIZATIONAL MODELS

There are several common models of HMOs, differing only in the relationships of the providers to the organization that is the HMO.

Staff Model

The Health Maintenance Organization employs the physician, and care is usually provided in a facility owned by the HMO. There is a high degree of control over care delivered, and thus premium costs are often lower in this type of structure due to the HMO’s ownership of the facility.

Group Model This type of HMO plan is structured around a multi-specialty medical group that may include internists, obstetricians, gynecologists, cardiac and oncology specialists and surgeons contracting exclusively with the HMO to provide services. Care is delivered in facilities owned either by the physician groups, such as clinics, or the HMO, such as a hospital.

Network Model This model is an HMO that contracts with many IPAs and other provider groups to form a “physician network.” Care can be provided in a larger geographic service area than would be possible with only one physician group. This network model offers the patient choice of physicians and managed costs.

Mixed Model This term describes certain HMO plans in which the provider network is a combination of delivery systems. In general, a network, or mixed model HMO, offers the widest variety of choices and the broadest geographic coverage to its members. Patients will often have a choice of clinics, labs, pharmacies, and hospitals as their providers of care.

1. Explain how new managed care contracts impact reimbursement for the healthcare organization.

Managed care organizations are driving market-level changes in the delivery of health care. First, the results provide evidence that managed care activity is associated with treatments and the cost of care for fee-for-service Medicare patients with AMI. Prior studies have found that managed care penetration affects the availability of technology in a market and the average cost of care for nonmanaged care patients. This study provides evidence that spillover effects influence the types of care that individual patients receive for specific conditions. Our results suggest that higher levels of managed care penetration are associated with reductions in the utilization of costly procedures such as revascularization and cardiac catheterization and increases in the use of low-cost preventive services such as smoking cessation counseling in fee-for-service patients.

Second, the results suggest that the spillover effects generated by managed care penetration are eroded somewhat by competition among managed care organizations, particularly the effects for costly procedures.

Referances:

http://www.who.int/bulletin/archives/78(6)830.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360998/

https://www.medicalbillingandcoding.org/try-coding

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1105592