1

Final Project Submission: White Paper

Name of author

Course title and number

Professor’s name

Date
 2

Table of Contents

Question 1. Reimbursement and the Revenue Cycle.......................................................................3

Section 2. Departmental Impact on Reimbursement.......................................................................6

Section 3. Billing and Reimbursement............................................................................................8

Section 4. Marketing and Reimbursement.....................................................................................12

References......................................................................................................................................14
 3

Question 1. Reimbursement and the Revenue Cycle

A.1 According to Rodgers, Francart, and Amerine (2023), the revenue cycle management

process entails collecting pertinent information during the patient encounter to facilitate

reimbursement. Based on the provided details, fees are levied for rendered services, compiled

into a claim, and submitted to obtain reimbursement. In order to expedite the payment process,

claims must be submitted in a timely manner. The provision of reimbursements is a crucial factor

in ensuring the continuity of operations for healthcare organizations by contributing to their cash

flow. The absence of payments would pose a significant challenge in managing a healthcare

organization, ultimately resulting in its cessation of operations. The Revenue cycle encompasses

the interactions between patients, payers, and providers. The flow of operations for Northeast

Georgia Medical Center significantly relies on reimbursement. The possibility of bankruptcy

looms over healthcare enterprises, as evidenced by the 22 healthcare organizations that filed for

bankruptcy in 2017 for diverse reasons (Salgia, 2018). The absence of reimbursement is a

significant factor contributing to the financial insolvency of healthcare enterprises.

A.2. Hospitals incur financial losses when they render services without receiving

corresponding payments. If this pattern were to recur frequently, it could result in an excessive

accumulation of negative financial obligations for the entity. Whenever a healthcare facility

renders a service, it utilizes resources and supplies financed from its budget. If compensation for

said services and supplies is not obtained, a budgetary discrepancy may arise, potentially

resulting in financial complexities for the organization.

A.3. The data that requires examination to ascertain the need for modifications would be the

revenue cycle management report, which evaluates the organization's capacity to generate

revenue from claims (Stark, 2022). Based on the available data, one could identify areas for
 4

potential improvement by assessing the organization's revenue generation efficiency and error

rate and evaluating any issues related to claims that may result in delayed reimbursement and

repeated rejections from insurance companies.

B. 1

B.2. The above is a depiction of the revenue cycle as described by Enter Financial. The

process starts when the patient is first enrolled in the hospital's system, and their details,

insurance details, and payment details are all recorded. The next step is to check the patient's

insurance to ensure they are covered for the necessary treatment. All expenses incurred by a

patient during their stay at the institution must be paid for using the patient's account. Billing

codes are derived from these costs. A bill is generated from the codes by billing. Billing

insurance companies electronically includes remittance posting (Stark, 2022). Claims that are

rejected or denied by an insurer, usually because of a mistake, may be processed using denial

management. Whether or whether the claim was paid by insurance, a final sum reflecting the
 5

patient's responsibility for payment is added to the patient's account. The revenue cycle

management report aims to assess the efficiency with which claims are processed and paid

(Stark, 2022).

C. 1. According to Qi and Han (2020), the revenue cycle at Northeast Georgia Medical Center

relies heavily on the work of the patient registration and health records management department.

The billing and coding staff is second only to the administration in importance. The office in

charge of denying requests would then act on them. Each of these divisions contributes to the

revenue cycle, but the cycle runs more smoothly when everyone is responsible for their errors

and held to high standards of performance (Stark, 2022)

C. 1a. The Northeast Georgia Medical Center is a big, non-profit facility that relies on patient

eligibility verification for payment (Qi & Han, 2020). Accurate information and insurance

coverage verification from the provider is required to properly determine a patient's eligibility.

The HIM team's responsibility includes keeping patient records up-to-date and in good standing

with the insurance provider. Most denied claims result from a human mistake in billing and

coding, which occurs early in the revenue cycle. Before submitting invoices for payment,

employees should double-check their work for mistakes. Changing a submitted or rejected claim

may be time-consuming and cumbersome (Harrington, 2019). The billing and coding teams

guarantee that the patient is charged for all rendered services and items and that the insurance

provider processes the claim. Finally, the rejection management division is responsible for

reviewing denied claims and attempting to correct them before resubmitting them. Denial is a

crucial element of the revenue cycle, but it won't be as necessary if the other departments do a

good job (Harrington, 2019).

 6

Section 2. Departmental Impact on Reimbursement

A. The Northeast Georgia Medical Center is a premier organization located in Georgia,

especially for its exceptional cardiovascular services. There are two major hospitals and several

outpatient clinics, as well as specialized centers for emergency medicine, family medicine,

obstetrics and gynecology, internal medicine, and pediatrics, all under the umbrella of this

institution. According to Zippia Score (n.d.), Northeast Georgia Medical Center, a non-profit

institution, receives more than $5 billion in yearly patient income. The success of this facility,

and those who like it, depends heavily on reimbursement information and the departments that

process it.

B. The company needs an internal audit to verify that all relevant divisions are making

maximum use of reimbursement funds. A company's internal audit objectively evaluates its own

financial and operational controls (Christ et al., 2021). The accounts are payable and receivable

ledgers are open to audits. They'll compare the two sources to look for differences. To determine

whether additional controls are necessary, auditors will evaluate how well existing policies and

procedures meet the company's compliance requirements. Internal auditors, management, and

oversight boards will develop a yearly audit plan based on a risk assessment of the business

(Christ et al., 2021). After the audit, a report is written detailing what was discovered.

Organizations may use audits to identify problem areas and take action on auditors'

recommendations.

C. The current payment structure is a pay-for-performance model in which doctors are

compensated more handsomely when their efforts lead to positive patient outcomes. Thus,

service providers incur costs under this method when they perform poorly (Yabroff et al., 2019).

There are three ways to calculate remuneration for performance bonuses. Three evaluation tools
 7

are at your disposal: structural, result, and process. Examining how well the IT infrastructure

caters to patients' requirements is a key part of structural measures. The percentage of doctors

who have completed residency programs and the ratio of doctors to patients are further examples

of structural metrics (Harrington, 2019). Regardless of illness, care plans for all patients are

evaluated using process measurements. All procedures and diagnostics prescribed by the care

plan must be carried out. The organization's effectiveness in diagnosing and treating patients is

the primary emphasis of process measurements. Surgical death rates, surgical complication rates,

and hospital-acquired infection rates are only a few of the metrics used in risk adjustment

models. One way to look at outcome metrics is as the end product of the overall healthcare

system.

D. The four factors that affect reimbursement are patient accounts, clinical services, health

information management, and administration. The patient account department uses the charge

master to create a payer bill and deliver it online or by mail. This department's effectiveness

depends on reliable patient service data. The institution risks losing or delaying compensation if

the information is wrong (Harrington, 2019). Clinical services handle registration, insurance

verification, and clinical documentation. These services let the hospital verify that the patient

received the services invoiced (Harrington, 2019). Clinical documentation includes who

contacted the patient, what treatments were provided, and other key clinical information that

helps patients make decisions while in the institution. This department's inaccurate paperwork

might affect patient treatment and facility compensation. The health information department soft

codes medical records, making it vital. After checking for correctness, the chart gets a code.

Insurance companies often refuse claims due to faulty paperwork and reporting. Due to

paperwork problems, hospitals cannot give free services without income. Administration
 8

transactions occur across the institution, including personnel remuneration, equipment, supply

purchases, and services provided by certain departments to others. The facility's management

staff evaluates all transactions affecting the organization's finances (Harrington, 2019). If

reimbursement cycle errors reduce income, management must adapt the budget to suit facility

demands.

E. The health information management and coding team must check for correct billing and

coding practices. This section is responsible for monitoring the implementation of all current

coding compliance rules. These divisions are responsible for the patient's financial obligations to

the healthcare provider, including examining charges and itemizing invoices (Harrington, 2019).

To ensure consistency among facilities and care settings, all divisions must document processes

and rules. The HIM and coding team's job is to ensure that all clinics in the hospital have access

to the same coding and clinical documentation training and standards. Coding clinics may help

the healthcare facility's coding personnel learn more about the compliance program and improve

patient care.

F. The impact of the department on reimbursement is noteworthy when it is obligated to

comply with established billing and coding standards and procedures. Accuracy in these areas

helps the company to evaluate its revenue cycle and reduce bad debt. Without an effective

revenue cycle, a company may be unable to pay its employees, purchase necessary materials, and

continue operations. Each section must collaborate to provide the highest potential income

without billing or paperwork errors.

Section 3. Billing and Reimbursement

A. Prior to initiating the claims filing process, it is advisable for patient access professionals

to rectify any inaccuracies, employs streamlined eligibility verification tools, familiarize

 9

themselves with patients' financial obligations, assesses patients' willingness to remit payment

and secure a portion of patients' payments in advance (Rich et al., 2018). The implementation of

these procedures within the patient access team has the potential to enhance cash flow and

diminish accounts receivable days. The implementation of effective data collection and

management strategies can help to reduce the risk of hospitals experiencing payment

delinquencies. Accurate data entry reduces the likelihood of rejection and resubmission,

speeding up payment from payers. Registrars need "software and tools that highlight critical data

elements and allow them to easily determine patients' plan statuses," writes Riley (2018). This

will help them more quickly analyze the issue and take the necessary action. For billing and

statistics purposes, customer service is crucial. Front-line personnel relies on clear and concise

communication to learn about patients, assist with billing and payment questions, and collect

feedback. According to Rich et al. (2018), maintaining transparent communication channels

between patients and patient access staff can facilitate a better comprehension of the patient's

financial status. This, in turn, can enable the staff to undertake appropriate measures to collect

payments by verifying the individual's health insurance coverage, copayment responsibilities,

and remaining deductible. When healthcare personnel provides clear information regarding the

billing cycle and the accuracy of the information, patients exhibit a decreased likelihood of

confusion and an increased likelihood of satisfaction and timely payment.

B. The Medicare Trust Fund relies heavily on the services provided by third-party medical

billing businesses. The healthcare industry often employs private organizations to promptly

handle insurance claims that comply with all relevant laws and regulations (McCarthy & Waugh,

2022). In essence, the compliance endeavors of a billing enterprise ought to foster an

environment that promotes the avoidance, identification, and resolution of occurrences of

 10

behavior that contravene Federal and State legislation, as well as Federal, State, and private

payer healthcare program mandates, in addition to the ethical and commercial policies of the

billing company (McCarthy & Waugh, 2022). The compliance program ought to unambiguously

articulate and exemplify the organization's commitment to adhering to legal regulations and

upholding the utmost ethical principles. As posited by McCarthy and Waugh (2022), the

integration of a compliance program into daily billing activities should be a gradual and enduring

process. The implementation of internal quality control mechanisms, such as compliance

programs, holds significant importance within the domains of reimbursement and payment.

C. Collecting up-to-date patient contact information at each visit is the best way to

maximize payment. Inaccurate patient data extends the payback period, which increases costs.

Organizations may lessen their exposure to the risk of nonpayment by adopting a financial triage

approach at the point of patient access. Hence, the significance of the front office lies in its

ability to optimize prompt reimbursement from external payers. Prior to submitting claims, it is

imperative for billing and coding professionals to ensure compliance with all relevant regulations

and rectify any inconsistencies identified. According to Rich et al., 2018, "Effective financial

triage strategies that start at patient access will set the organization up to receive maximum

patient and payer payments by reducing the number of claims denied because of typographical

and demographic errors and gathering as much information as possible before the procedure will

give visibility into third-party payer responsibility ."Expert billers may ascertain a patient's

tendency to pay and the amount the patient is accountable for, providing transparency into the

accounts receivable process.

D. It is imperative to maintain a comprehensive log of all subsequent telephone

communications for the patient's medical dossier and internal hospital evaluation. Monitoring
 11

this data would facilitate improved quality management and advancement. It is recommended

that documentation be made regarding call attempts, patient health, treatment issues,

appointment status, put-up-discharge activities, and staff follow-up. To guarantee the fulfillment

of the facility's objectives, it may be necessary to establish a monitoring team that oversees

progress, identifies obstacles to a more structured follow-up system, enforces employee

adherence to performance targets, and encourages the dissemination of insights gained from

workplace incidents. The constitution of a monitoring team necessitates the incorporation of

insights from a diverse array of facility departments, encompassing nursing, medical, case

management, information technology, and other relevant domains.

E. Compliance programs serve to mitigate the occurrence of audits, fraudulent claims, and

ethical dilemmas. The Office of Inspector General (OIG) has developed numerous guidance

papers on compliance education programs for various healthcare sectors. The successful

implementation of a compliance program can be achieved by following the seven stages as

outlined by The Office. Initially, it is imperative to establish formally documented policies,

procedures, and codes of conduct. The second step in ensuring compliance involves designating

a CO and a CC to oversee the compliance program. Thirdly, it is imperative to exercise caution

when delegating authority. The fourth step involves the implementation of training and

communication strategies. Step five involves the process of internal auditing. The sixth step

involves the implementation of unambiguous disciplinary policies. The seventh step involves

promptly rectifying any transgressions. Given adequate supervision and authority to evaluate and

manage implementation, this approach could be operationalized within the organization.

 12

Section 4. Marketing and Reimbursement

A . Financial strategies need managed care contracts (Payorhealth, N.d.). Contract

negotiation should address the payer's role. Establishing a provider-payer connection before

negotiating is important. This depends on the relationship's length and the organization's goals.

The organization's main mission is equitable service remuneration. However, there are others.

Organizations must negotiate net changes, not rates. To get a comprehensive agreement for the

organization, auxiliary providers and doctors must be included in talks. Pre-negotiations payer

profiles should be detailed. Steps to develop a complete payer profile: Contact the contractual

party, examine internal claims data, and interview operational workers.

B. Through contractual and financial ties, all managed care system participants and

stakeholders share financial risk and have some influence on the use and pricing of covered

services (Reichman et al., 2021). The managed care contract is in everyone's best interest,

including healthcare providers, health plans, plan sponsors, and people. To effectively manage

care contracts, each department within an organization must perform its assigned tasks promptly

and precisely. According to Paula Dillion, “Rockford Health System's director of managed care,

we connect with about 70 key operations staff before a payer negotiation and ask about what's

working and not working." This provides information on "intangibles such as payer

responsiveness, rep knowledge, willingness to problem solve, and so on" (Reichman et al.,

2021).

C. A healthcare provider may expect to get most of its income through managed care

contracts. Contracts that are successfully negotiated protect existing income streams and open up

new ones through insurable services and strategies. A well-managed care contract may also

improve patients' overall well-being by giving them easier access to a wide range of necessary
 13

medical care. The director of managed care at Rockford Health System told the Healthcare

Financial Management Association (2017) that "approximately 30 percent of our revenue comes

from managed care."

 14

References

Christ, M. H., Eulerich, M., Krane, R., & Wood, D. A. (2021). New frontiers for internal audit

research. Accounting Perspectives, 20(4), 449-475.

Harrington, M. K. (2019). Health Care Finance and the Mechanics of Insurance and

Reimbursement. Jones & Bartlett Learning.

Healthcare Financial Management Association. (2017). Successfully Negotiating Managed Care

Contracts. Retrieved April 19th 2023, from http://www.hfma.org/Content.aspx?id=16658

McCarthy, D., & Waugh, L. (2022). The Influence of National Standards on Medicaid Managed

Care Programs: Implications for Children and Youth with Special Health Care

Needs. Maternal and Child Health Journal, 26(10), 1967-1975.

Payorhealth. (N.d). MCOS UNDER THE MANAGED CARE SYSTEM. Retrieved on 19TH

April from: https://payrhealth.com/resources/blog/tips-for-negotiating-managed-care-

contracts/

Qi, K., & Han, S. (2020). Does IT Improve Revenue Management in Hospitals?. Journal of the

Association for Information Systems, 21(6), 7.

Reichman, V., Brachio, S. S., Madu, C. R., Montoya-Williams, D., & Peña, M. M. (2021,

February). Using rising tides to lift all boats: Equity-focused quality improvement as a

tool to reduce neonatal health disparities. In Seminars in Fetal and Neonatal

Medicine (Vol. 26, No. 1, p. 101198). WB Saunders.

Rich, J., Fonner, C. E., Eller, J., Berkel, I., & Nadzam, D. (2018). Maximize reimbursement and

minimize risk under the medicare access and children’s health insurance program

reauthorization act (macra) and the quality payment program (qpp). The Annals of

Thoracic Surgery, 105(5), 1299-1303.

 15

Rodgers, J. K. L., Francart, S. J., & Amerine, L. B. (2023). Establishing a pharmacy revenue

integrity team: A blueprint for increasing pharmacy’s role in health-system revenue

cycle. American Journal of Health-System Pharmacy, zxad067.

Salgia, A. (2018). The Clinically-Driven Revenue Cycle. Emergency Medicine News, 40(2C),

10-1097.

Stark, J. (2022). Product lifecycle management (PLM). In Product Lifecycle Management

(Volume 1) 21st Century Paradigm for Product Realisation (pp. 1-32). Cham: Springer

International Publishing.

Yabroff, K. R., Gansler, T., Wender, R. C., Cullen, K. J., & Brawley, O. W. (2019). Minimizing

the burden of cancer in the United States: Goals for a high‐performing health care

system. CA: a cancer journal for clinicians, 69(3), 166-183.

Zippia Score. (N.D). NORTHEAST GEORGIA HEALTH SYSTEM REVENUE. Retrieved

on 19th April 2023 from: https://www.zippia.com/northeast-georgia-health-system-

careers-311300/revenue/