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Uploaded by AdmiralProton12466
Niyoca Daley
HCM-345-T2066 Healthcare Reimbursement
Candice Faison
December 3, 2023.
Third-party policies are designed to maximize reimbursement. They are utilized to establish
billing guidelines by patient financial services personnel and administration for determining the
payment mix to achieve maximum reimbursement. These policies ensure that the Patient
Financial Guidelines (PFG) include all essential elements for maximizing reimbursement. Patient
financial services (PFS) personnel play a crucial role in processing and monitoring
reimbursement aspects of claims. PFS employers analyze reimbursement, identify errors, and
make necessary changes to maximize reimbursement. PFS personnel, by following third-party
policies, contribute to determining the coverage specified in contracts with third parties. They
understand which services or items are fully or partially covered for reimbursement. To ensure
maximum reimbursement, third-party policies
mandate timely and accurate entry of all
information collected by PFS and administrators into the system. Key areas of review include
patient registration and verification, medical coding, diagnosis, contractual agreements, and
modifiers. This information provides insurance companies with accurate details about the
patient's diagnosis and treatment. Patient registration and verification, being the first step in the
billing process, involve a thorough review of patient information by necessary staff or providers.
Providers, responsible for selecting and treating a patient's diagnosis, must code visits correctly
and ensure their notes align with the patient's diagnosis or treatment. ICD coding is used to
determine payment categories for various Prospective Payment Systems (PPS). Hospitals use
ICD-10, CPT, and HCPCS codes to maximize reimbursement. Some third-party payers negotiate
discounted rates through contracts, establishing cost-sharing agreements between payers and
providers. Providers submit claims, receiving 80% of the contracted amount from the third-party
payer and billing the patient for the remaining 20%. Effective follow-up staff requires proper
training and resources to manage diverse cases encountered daily. Thorough and extensive
training equips follow-up staff with the necessary tools to address varying cases. Establishing
open communication with the PFS department and relevant departments, implementing
predictive analysis tools, and periodically reviewing reimbursement contribute to the
effectiveness of this structure. A plan for periodic review ensures alignment with the latest
regulations, reducing the risk of noncompliance. A well-structured compliance program includes
a compliance plan detailing standards and procedures, oversight and administrative aspects,
education and training, monitoring and investigating, reporting compliance issues, guidelines for
reporting, and corrective action plans.
Managed care is a healthcare delivery model aiming to provide high-quality healthcare while
controlling costs. The four primary organizations in managed care are Health Maintenance
Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS)
organizations, and Exclusive Provider Organizations (EPOs). The structure of managed care
organizations can impact reimbursement, with contracts often featuring value-based payment
models tied to achieving health outcomes. Errors in billing and coding can have serious
consequences, including fraud, legal costs, loss of reputation, and criminal penalties. Ensuring
compliance with regulations and ethical standards is crucial. Billing and coding staff should be
properly trained and possess the necessary competencies. Creating a culture of compliance,
encouraging staff to report concerns, staying informed about changes, and adhering to
documentation policies are essential. Quality improvement efforts involve stakeholders who
provide valuable perspectives during planning, conducting, and interpreting evaluations.
Stakeholders offer insights into unintended consequences and patient experiences, enriching the
evaluation process. Involving stakeholders ensures ethical practice, enhances evaluation
questions from the start, and increases the impact of evaluations by addressing potential issues in
advance.
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