Assignment: HSNCB 476 Competency 2

Assignment: HSNCB 476 Competency 2

Assignment: HSNCB 476 Competency 2

All health care organizations must be aware of cost controls, regardless of nonprofit or for-profit status. Managing costs at all levels of the organization affects the bottom line, which has a direct effect on all aspects of the organization. This assessment is designed to help you analyze why organizational policies are put in place. In addition, it will help you understand the role of Operations in a health care setting, which is to ensure a high quality of care is maintained across all departments.

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You are working in an organization that is conducting an audit of a determined number of policies to determine if they are effective in their current state or if improvements and updates are needed (and alternatives need to be created).

Your first step is to find a policy at a health care organization related to cost controls. Include the following in your report:

Summarize the details of the policy:

When was the policy put in place?

Was it adopted system-wide, in one department, or multiple departments?

What does the policy address?

What is the potential impact of not following the policy at the organizational level? Unit level? Individual level?

Explain how the policy impacts fiscal aspects of the organization:

How does the policy act as a cost control?

Describe how the policy impacts the quality of patient care:

Does the policy improve efficiency?

Are the goals to improve care and reduce costs?

Explore the unintended consequences:

What secondary impacts does the policy have on the organization? Unit? Staff? Patient?

Does the policy need revision?

Suggest alternatives to the policy:

In your opinion, is the policy the best way to address the issue? Support your position by explaining why or why not.

Note: Students who do not work at a facility can research a policy related to cost controls by locating a facility and conducting an interview “virtually” (e.g., Zoom or by phone). or the student could research a facility’s policies without conducting an interview.

Format your assignment as 1 of the following:

875-word paper

Another format approved by your instructor

Cite at least 3 evidence-based, peer-reviewed sources published within the last 5 years in an APA-formatted reference page to support your position(s).

Include an APA-formatted reference list.

Submit your assessment.

Assignment: HSNCB 476 Competency 2 Sample

The previous several years have been difficult for hospitals and medical organizations due to a lack of employees, pandemics, and continuously shifting laws. Hospital profitability and revenue cycles have declined as a result of these problems. Low clean claim rates, according to the Healthcare Financial Management Association (HFMA), have a significant detrimental effect on the revenue cycle. For optimal payouts, industry experts advise aiming for a clean claims rate of at least 90% (Colorado Title 10. Insurance § 10-16-106.5, n.d.). The chosen policy for this project is Clean Claim Reviews, which is categorized as a payment integrity policy.

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Summary of the Policy

            During the early stages of the COVID-19 epidemic, the healthcare organization introduced the “Clean Claim Reviews” policy (Healthcare, n.d.). It was embraced on a systemic level. The utilization review and utilization management (UR/UM) notes, health records, and past denials are all examined as part of a Clean Claim Review, a pre-payment cost containment strategy, to find and eliminate discrepancies that would have been covered by the patient. Clean Claim Reviews make sure that patients are not being overcharged and that invoices are correct.

            Due to the rigorous requirements that insurers must abide by, companies occasionally have to modify their standard operating procedures. If the policy is not adhered to, claims will be rejected for improper patient care. Other factors that could lead to a claim being rejected are missing pre-authorization or pre-certification forms, inadequate supporting documentation, dates of services that overlap, incomplete or lately submitted documentation, claims for expensive treatments or medications, and overlapping service dates (Thaker et al., 2020).

Policy and Fiscal Aspects of the Organization

            Clean claim rates are crucial for ensuring that the full income is realized quickly and for avoiding unnecessary labor expenditures. The accuracy and lack of inaccuracies in the data you are gathering are shown by a high clean claim rate. The promptness of payment is impacted by claims inaccuracies. Aiming for a clean claim rate of 90% or better will guarantee a higher settlement rate (Merritt-Myrick & Harris III, 2020). Late payments also result in fewer claims that need to be reviewed and reworked by billing personnel.    

Quality of Patient Care

Reduced rejections and improved reimbursement for healthcare organizations depend on clean claims. Timely and correct claim submissions result in prompt payouts, which increase operating margins (Thaker et al., 2020). When the hospital is adequately compensated for the services given, high-quality patient care may be offered more effectively. Claims that are accurately billed directly support the caliber of service.

Unintended Consequences

Everyone involved in creating the claim, from the patient access staff at registration to the clinicians providing care to other healthcare professionals involved in generating the claim, must have the training and knowledge necessary to gather accurate information about a patient, their insurance, the procedures they underwent, and the connections between those elements (Williams et al., 2020). It might be difficult to keep up with changes in payer billing policies. For many people, keeping up with these developments is a full-time job. Payer rule changes may go unnoticed if there are subpar system rules upstream or a lack of interaction between provider financial and clinical systems, which makes it simple for CCR to spread.

A 100 percent CCR may be unrealistic given that upstream faults and data quality concerns are difficult to eliminate, and payer standards are always changing (Merritt-Myrick & Harris III, 2020). Nonetheless, some businesses have achieved this goal by putting the appropriate personnel, procedures, and technological resources in place. Even with substantial expenditure, the majority of providers operate with CCRs between 70 and 85 percent. Strong systems integration, ongoing efforts to maintain system rules streamlined, and efficient staff training all contribute to a CCR that exceeds 90%.

Alternatives to the Policy

A reputable vendor of RCM services committed to raising your clean claim rate will go above and beyond to avoid submitting a claim that will not be authorized. Claims scrubbing is a checkpoint mechanism that your medical billing partner ought to provide (Williams et al., 2020). To prevent claims from being denied, it is essential to always be aware of payer requirements. RCM service providers make sure your claims are accurately coded before submission by staying up to speed on all medical coding. When a claim is denied, it usually happens because the claim was submitted too late or with inaccurate coding. Claims cleaning makes sure that code problems are discovered right away and rapidly fixed before submission. Providers may rest easy knowing that their clean claim rate will increase by working with a medical coding specialist.

All employees who work on any aspect of the revenue management cycle should also receive training on the value of a high clean claim, frequent mistakes that occur, and how to fix them (Merritt-Myrick & Harris III, 2020). Both during and after deployment, your software provider or partner in medical billing should provide training. Even if your partners are working hard to raise your clean claim rate, you will notice greater progress if your team is well-versed in good billing procedures and how to use medical billing software.

Conclusion

The clean claim rate is one of the strongest indicators of the work your healthcare organization is putting into the revenue cycle process to get claims invoiced, albeit it may not be the sole indicator of billing effectiveness. Although there will always be corporate and system factors pushing against you and your CCR, it is entirely feasible to reduce error-related costs significantly with the appropriate people, procedures, and technology in place.

References

Colorado Title 10. Insurance § 10-16-106.5. (n.d.). Findlaw. Retrieved March 21, 2023, from https://codes.findlaw.com/co/title-10-insurance/co-rev-st-sect-10-16-106-5.html

Healthcare, B. (n.d.). Why tracking your clean claim rates isn’t enough. Go.beckershospitalreview.com. Retrieved March 21, 2023, from https://go.beckershospitalreview.com/finance/why-tracking-your-clean-claim-rates-isnt-enough

Merritt-Myrick, S., & Harris III, D. (2020). Successful Billing Strategies in the Hospital Industry. International Journal of Human Resource Studies, 11(1), 85. https://doi.org/10.5296/ijhrs.v11i1.18212

Thaker, N. G., Holloway, J., Hodapp, C., Mellen, M., Fryefield, D., Meghani, R., Tong, K., & Rose, C. M. (2020). Automated Big Data Analytics for the Radiation Oncology Alternative Payment Model Proposal Using a Novel Health Care Software Technology. JCO Oncology Practice, 16(4), e333–e340. https://doi.org/10.1200/jop.19.00692

Williams, D., Reiter, K. L., Pink, G. H., Holmes, G. M., & Song, P. H. (2020). Rural Hospital Mergers Increased Between 2005 and 2016—What Did Those Hospitals Look Like? Inquiry: A Journal of Medical Care Organization, Provision, and Financing, 57. https://doi.org/10.1177/0046958020935666