Dawn Quackenbush 1

5-2 Final Project Milestone Three: Draft of Billing, Marketing, and Reimbursement

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.

Patient access personnel are essential in the collection of data. It starts with the front desk
staff and schedulers. They are the ones to enter patient demographics, this information must be
entered accurately to ensure the beginning of the billing process. Next step is the accuracy of
documenting the patient's visit, the staff will make sure all compliance required information is
documented on the patient intake forms. This information is crucial in meeting performance
goals. The physician then documents his findings to support any billing claims and any future
testing or procedures needed. All of these steps help to coders in choosing the most accurate
codes. The billing and coding department must be extremely accurate to obtain the best payment
for the practice and the patient. Inaccurate billing and coding can have serious financial
consequences. When there are accurate billing and coding protocols in place it can help ensure
the compliance and financial best for the practice. Accurate billing also allows practices to
analyze the data on revenue and costs which help with future financials (HIS, 2017).

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.

Patient financial services personnel is a role that monitors the reimbursement process. They
analyze the reimbursement process and also find changes to maximize the reimbursement.
Knowing the third party policies will help PFS personnel to determine what is needed for the
most accurate reimbursement afforded. They need to know what test or procedures are covered
through each contract.

C. Organize the key areas of review in order of importance for timeliness and maximization of

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reimbursement from third-party payers. Explain your rationale on the order.

1) Negotiating successful contracts with payors.
2) Performing insurance verification for all scheduled patients
3) Processing claims electronically.

First is negotiating successful contracts with payors. This is important to have participating
insurance companies and knowing each covered tet and procedures. Second is performing
insurance verification and eligibility on all patients scheduled. This process will ensure the
patient has insurance, it is active and the insurance is one that the provider participates in. Third
is filing claims electronically. This process is faster and more accurate. Electronic claims lead to
less errors as well as receiving reimbursement faster and more effectively for the practice.

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

A team can be formed to ensure the practice is meeting all requirements and achieving the
most for its reimbursement. This team can identify any barriers and help implement any changes
that need to be made. Setting goals, holding and teammates accountable and teaching from
mistakes is a way to monitor and follow structure.

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.

Developing an effective compliance plan is a statement a practice intends to conduct itself

ethically in regard to business. The objectives are to explain why compliance plans are
important, review federal fraud and abuse laws and to describe the seven essential elements of an
effective compliance plan . Compliance plans are a requirement by law. First would be to
develop a compliance team who knows all the 7 essential elements. This team will designate a
compliance officer to provide insight on programs. Next would be writing policies, procedures
and conduct standards. This team will educate employees and develop lines of communication.
Compliance teams will monitor and perform audits, they will respond promptly and undertake

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corrective actions.

Marketing and Reimbursement

A. Analyze the strategies used to negotiate new managed care contracts. Support your analysis
with research.
There are six strategies to negotiating a managed care contract (Duprey, 2010)
1) Know your market, your competition and network competition. The provider needs to
understand their place in the market. The provider also needs to be able to show their
value and what they can bring to the network.
2) Build your network participation based on referral sources. By developing relationships
with other providers will help ensure referrals to them.
3) Understanding costs and profit margins before you negotiate rates. It is important to
understand pricing before negotiating.
4) Be aware of contract terms that could negatively impact your business.
5) Negotiate a smart rate.
6) Know when to walk away.

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.

Managed care contracts rely on each entity of an organization to perform their duties timely
and most accurately. All participants of a managed care system are contractually linked. Each
partner shares financial risks.

C. Explain how new managed care contracts impact reimbursement for the healthcare
organization. Support your explanation with concrete evidence or research.

Managed care contracts represent a big portion of the healthcare organizations revenue.
Negotiating contracts help preserve revenue and improve patient satisfaction. With negotiating a

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contract it ensures testing and procedures are covered.

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.

There are strategies to ensuring coding compliance. Identifying red flags, evaluate your audit
risk, update coding staff (Clements, 2017). Medical coders must follow ethical guidelines, and
they must apply accurate coding practices. If compliance is not followed the organization runs
the risk of fines, denial of claims, dismissal of contracts and the loss of employment.

References:
Healthcare Information Services. (n.d.). The Importance of Accuracy and Compliance in Billing
and Coding. Retrieved from https://blog.healthinfoservice.com/accuracy-and-compliance-in-
billing-and-coding.

RevCycleIntelligence. (2019, October 18). Key Ways to Improve Claims Management and
Reimbursement in the Healthcare Revenue Cycle. Retrieved from

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https://revcycleintelligence.com/features/Ways-Improve-Claims-Management-and-
Reimbursement-in-the-Healthcare-Reve.

Orseno, M., & Regent Surgical Health. (n.d.). Maximize Reimbursement: 4 Strategies for
Success. Retrieved from https://www.beckersasc.com/asc-coding-billing-and-
collections/maximize-reimbursement-4-strategies-for-success.html.

Oandp.com. (n.d.). Six Steps to Managed Care Contracting. Retrieved from

https://opedge.com/Articles/ViewArticle/2010-07_07.

Clements, J. (2017, January 17). Know the Strategies to Ensure Coding Compliance in 2017.
Retrieved from https://www.outsourcestrategies.com/blog/strategies-to-ensure-coding-
compliance-in-2017.html.

Inc. (2019, December 1). Retrieved from http://www.hcpro.com/HOM-236942-5728/know-your-

ethical-obligations-regarding-coding-and-documentation.

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