Question 1: Ensuring compliant coding and billing
Adhering to accurate coding and billing processes is one of the most important elements in ensuring RCM coding and billing compliance. A critical process that can be used to ensure RCM practices comply with coding and billing regulatory guidance and industry standards is regular monitoring and auditing of medical claims before submission for payments such as the ICD-10 standards (CureMD, 2016; Kochhar, n.d.). Frequent request follow-up and verification activities improve and strengthen the overall coding and billing processes of a firm by helping ensure that all the necessary right safeguards are in place to avoid errors (MetricStream Inc., 2016). Adequate training and education of RCM staff can contribute to support and improve this activity.
Question 2. Establishing a Fee Schedule
If I were responsible for establishing a fee schedule for my practice, I would prefer the Resource-Based Relative Value Scale (RBRVS). RBRVS is a standardized schema used to determine in monetary terms how much a physician is paid for the medical services rendered (American Medical Association (AMA), 2016). In this system, the resource costs needed to provide a medical service are used to determine the required payments for the services. The service provision cost for each service is categorized into three main components: the practice expenses, the physician work, and the professional liability insurance cover (AMA, 2016). The procedure for determining the service prices using this method entails assigning a Relative Value Unit (RVU) to all the medical services rendered by a physician adjusted by the geographic region the physician is situated. This value is then multiplied by a fixed conversion factor (a standard monetary amount determined by the Centers for Medicare and Medicaid Services) to determine the amount of payment. I will prefer using the RBRVS method because it is one of the best ways a private insurer can use for both pricing and for studying and establishing variation in claim expenses. Secondly, unlike other methods such as the Evidence-Based Medicine (EBM), RBRVS advocates for fair and accurate valuation of all physician services. It achieves this function by factoring in the total physician work including the doctor’s mental efforts, judgments, and an amortization of the education level of the doctor in determining payments for his/her service (AMA, 2016).
Question 3: Improving Claims Data
The techniques I would suggest for improving the accuracy of claims data in the practice is the use of Data-Driven techniques such as Predictive Analytics (PA). These techniques employ the use of both technology and statistics to improve not only the accuracy but also the legitimacy of claims data in the Healthcare practice (Winters-Miner, 2014). I think these techniques will work because the use of PA come a long way to help in searching through the massive amounts of claim information as well as analyzing the individual sets of data to predict possible application outcomes for patients both fast and with increased precision. I will implement these techniques in the practice mainly to improve the accuracy of the claims data (Cummins, n.d.). To achieve this, I will employ the techniques alongside adjusters to flag the claim applications for closer inspection (Winters-Miner, 2014). Investing in technology initiatives, wide inter and intra-sectoral IT consultation and collaboration as well as staff training are some of the ways I will use to implement the Data-Driven techniques in the practice.
Question 4: Practice Fee Schedules and Payer's Allowable Reimbursement
A practice fee schedule is a list of prices which reflects what an HMO is willing and would like to be paid for the services it provides. The Payer’s allowable reimbursement, on the other hand, refers to the maximum amount an insurer is required to pay for a particular service (AMA, 2016). For in-network service providers this amount is determined by the payer-insurer terms of the contract. However, for out-network providers, the Payer’s Allowable Reimbursement is determined by several factors such as the Usual Customary and Reasonable (UCR) charges or a percentage share that Medicare would pay for the same service (Cohen, n.d). For the practice, this difference helps the office estimate how much to charge for a service and how much the payer will owe for an office visit or procedure. For a consumer, the difference means approximating the amount to be paid for a service.
Question 5: Adjudicating Claims
Payers usually review claims before adjudicating them to ensure that the complaint is accurate to the smallest detail (Cohen, n.d.). If there is a detection of inaccuracy, the insurer will enter payment appeals, and in worse cases fail to pay the claim altogether. The most common reason I think payers initially determine that payment for a service is not due to the practice is the existence of errors or mistakes in the initial requests for payment. Another reason I think so is the practice’s non-adherence to the payer’s payment policy (such as time limits for filing claims) when filling for the claim. These are the common reasons because they include areas where requests for payments usually go awry and thus determines whether the claim is valid (or compliant) and if so how much the payer will pay.
Question 6: Explanation of Benefits (EOB) Methodology
When there is a payment rejection for a service claim, the Explanation of Benefits (EOB) mailed to the practice usually contains the reasons to that end (Patient Advocate Foundation, Inc., 2012). Consequently, the line item in question relieves the A/R. EOB is usually a preferred methodology as the practice is accorded a platform to seek clarity on the matter as well as exploring possible avenues for filling a coverage appeal for the claim. Additionally, the EOB usually provides the client with a summary of the prescription drug claims and the corresponding cost (Patient Advocate Foundation, Inc., 2012). Personally, I agree with this payment plan because besides providing the information for the services rendered it also contains information for the determination of both the provider and patient coverage plan as well as the benefits payment information. Moreover, it is comprehensive in nature as it identifies the vendor, details the payment plan, and indicates as accurately as possible who was paid for the service by whom, when, and by how much.
Question 7: Checking Insurance Eligibility
Question 8: Reviewing A/R Reports
A/R (Accounts Receivable) describes revenue owed to the practice by patients and other third-party payers. A/R management is not only a vital management function but is also required to monitor and follow-up on outstanding accounts. Because the financial stability of a practitioner is highly dependent on the maintenance of an active and steady inflow of revenue to cover patient care expenses a report of 60%, A/R greater than 90 days means that the hospital takes 90 plus days to address its outstanding accounts (Roberts, 2014). This situation if uncorrected indicates trouble in the revenue cash flow of the hospital. It also shows that 60% of the practice’s due payment is greater than 90 days of work. Improving the A/R percentage will require the service provider to improve upfront collections of monies such as copays and service deductibles for those with high deductible health plans.
Question 9: Health Benefit Exchange Plans
The Health Benefit Exchange Plans are offered by organizations set up in agreement with the Patient Protection and Affordable Care Act (ACA), to facilitate the patient purchases of health cover policies (AMA, 2016). While these plans offer comprehensive medical cover to patients, they bear huge financial burdens to the patient with the premium mainly costing too much for most people. The extended grace period allowed in most such plans is not a good idea as it gives an avenue for the termination a plan when one fails to pay the pending premiums and will then be required to pay for the entire service bill for the default period. The practice can handle these balances by regularly checking the patient insurance eligibility and coverage every time the patient visits the office.
Question 10: Paying for Services
While providers accept payment for services in a variety of ways from credit cards to cash, a combination of the two or through other means such as third-party insurance payment methods, credit cards offer advantages for beyond mere payment convenience (Bank of American Corporation, 2016). They are incredibly a useful tool when it comes to emergencies and carry significant benefits for both the health practitioner and the consumer. For one thing, the provider gets paid for services upfront that goes a long way in cutting down the administrative cost of the practice. For consumers, they are more secure to carry around than cash and prompt payback results to zero interest rate charges and offer additional perks to customers in the form of waived prepayment penalties. They also have a positive effect on the consumer credit score when used wisely, regularly, and making payments on time (Bank of American Corporation, 2016). This choice depends on convenience and the potential perks a method of payment can attract.
Question 11: Training Techniques
Training revenue staff on how to consistently and more efficiently incorporate technological tools into the clinical care revenue cycle is one of the most important technique (Colwell, 2015). Proper and adequate understanding of using technological implements such as copyright registries, reminders, medical billing, and practice management software are helpful in streamline workflow and getting claims paid faster as the industry is rapidly moving towards alternative and technology-based payment models (Colwell, 2015).
Question 12: Internalizing vs. Outsourcing
There are several reasons usually taken into account when considering options for internalizing or outsourcing the revenue cycle functions of the practice. However, cost and related financial spin-offs, organizational size, and the shifting health care environment are some of the most compelling reasons. According to Ellison (2015), this is because outdated RCM systems lack the ability to work complex payment models supported by a multi-provider bundle thus disadvantaging the firm in the current tech-savvy environment. Fear of employee layoff, bankruptcy, and industrial pressure to invest in payment reforms are some of the least compelling reasons especially for firms that are financially stable. To them, they can alter their capacity margin with or without resource internalization or outsourcing depending on the requirements of the enterprise (Ellison, 2015). They can, therefore, vary their ability to provide services without long-term commitment to permanent infrastructure or staff to either,
Question 13: Tracking KPIs
Measurement and tracking of Key Performance Indicators (KPIs) are a critical way of gaining an objective understanding of improving the performance of practice. However, identifying the right KPI is usually not that straightforward because there are a lot of measures to consider and no single metric or sets of parameters is universally right to all service providers. Some of the elements to consider when considering which KPI to track include consistency, ‘actionability’, and the ease of communication (CA Technologies (NASDAQ), 2015). In deciding whether an Internal or External KPIs benchmark is more appropriate, better and deeper understanding of what is important to the firm and the clients is of utmost significance. The determination of the appropriate parameter will, therefore, be based on the analysis of the effectiveness of the available alternatives to pick the option that makes the most sense to the firm. This decision will require comprehensive utilization of the Behavior, Performance, and Perception Matrices.
References
American Medical Association (AMA). (2016). Overview of the Resource-Based Relative Value Scale (RBRVS). Retrieved March 30, 2016, from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/overview-of-rbrvs.page?
Bank of American Corporation. (2016). The Advantages of Credit Cards and Using Credit. Retrieved March 30, 2016, from https://www.bankofamerica.com/credit-cards/education/advantages-of-credit-cards.go
CA Technologies (NASDAQ). (2015). Key Performance Indicators: Establishing the Metrics that Guide Success. Retrieved from CA Technologies (NASDAQ) website: http://www.ca.com/us/~/media/Files/whitepapers/key-performance-indicators.pdf
Cohen, F. (n.d.). Chapter 8: Building a Defensible Fee Schedule: An Analytical Approach to Establishing and Maintaining Charges. In Best Practices: A guide for Improving the efficiency and quality of your service. Retrieved from http://www.cruzmed.org/portals/8/assets/pdf/chapters/best_practices_8.pdf
Colwell, J. (2015, September 11). Training Staff on Tech Tools Optimizes the Revenue Cycle | Physicians Practice. Retrieved March 30, 2016, from http://www.physicianspractice.com/revenue-cycle-management/training-staff-tech-tools-optimizes-revenue-cycle
Cummins, R. (n.d.). American Health Information Management Association (AHIMA): Coding Connections in Revenue Cycle Management. Retrieved March 29, 2016, from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027450.hcsp?dDocName=bok1_027450
CureMD. (2016). Top Revenue Cycle Management (RCM) Company. Retrieved March 29, 2016, from http://www.curemd.com/revenue-cycle-management/
Ellison, A. (2015, February 2). Solving the revenue cycle paradox: What options do struggling hospitals have? Retrieved March 30, 2016, from http://www.beckershospitalreview.com/finance/solving-the-revenue-cycle-paradox-what-options-do-struggling-hospitals-have.html
Kochhar, D. (n.d.). Regulatory Impact on Revenue Cycle Management— Think You’re Prepared? Think Again. Retrieved from GENPACT website: http://www.genpact.com/docs/resource-/regulatory-impact-on-revenue-cycle-management
MetricStream Inc. (2016). Audit for Reducing Medical Coding and Billing Errors. Retrieved March 30, 2016, from www.metricstream.com/solution_briefs/medical-coding-billing-errors.ht
Patient Advocate Foundation, Inc. (2012). Understanding Your Explanation of Benefits. Retrieved March 30, 2016, from http://www.patientadvocate.org/index.php?p=441
Roberts, L. W. (2014, January 22). A/R Primer for Medical Practices [PDF Document]. Retrieved from https://instructure-uploads.s3.amazonaws.com/account_20010000000000001/attachments/1194426/AR-primer-for-medical-practices.pdf?AWSAccessKeyId=AKIAJFNFXH2V2O7RPCAA&Expires=1459407975&Signature=0U2nbGpNsPfIA0jvRhUXxORqnCA%3D&response-content-disposition=attachment%3B%20filename%3D%22AR-primer-for-medical-practices.pdf%22%3B%20filename%2A%3DUTF-8%27%27AR%252Dprimer%252Dfor%252Dmedical%252Dpractices.pdf
Winters-Miner, L. A. (2014, October 6). Seven ways predictive analytics can improve healthcare. Retrieved March 30, 2016, from https://www.elsevier.com/connect/seven-ways-predictive-analytics-can-improve-healthcare
