In the past Parallon has had limited opportunities for en masse analysis. Requirements for analysis include unit number, patient number, client information, payor and payment information, and general logic. Improving Parallon’s accounts receivable process required a standardized analysis process. Accounts eligible for analysis do not have Medicare as a primary insurance, and secondary was present. All accounts must be in accounts receivable or collections agency status. Organizing accounts into three specific categories assisted in developing decisions based on account criteria. Account separation methods included accounts without a primary or secondary payment processing, accounts above threshold, and accounts with a denial code. Conflicting processes result in the inability to review denial accounts through this standardized process. Placing thresholds on financial classes limits the amount of errors possible due to contract agreements and rates. Payment percentages determine if accounts meet payment threshold requirements for analysis.
Account payment percentages range from 0% to over 100%, depending upon the payor. Payment percentages determine effective collection processes and contract efficiencies. All accounts with a payment percentage of 0% were considered to be below threshold if the
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balances met the threshold criteria, but were not adjusted. Accounts that have payment percentages of 0% or less indicate poor collection and payor follow up processes. Those 0% payment accounts are under review through a collection’s workflow process known as Unpaid Claims. Analysis has been performed on 62,319 accounts. Of the 62,319 accounts, 54,919 accounts had a payment percentage of 49.99% or less, and 7,400 accounts had a payment percentage of 50% or greater. Adjustments totaling $1,697,066.11 were performed using the processing criteria. $1,120,688.36 was submitted for accounts with payment percentages of 49.99% or less. $576,377.75 in adjustments were submitted for accounts with payment percentages of 50% or more. Variations on inventory was discovered due to facility size. Of the 50 facilities included within the analysis, facility number three was found to have much larger revenues than all other facilities. This implies that depending on a facility’s size accounts receivable inventory will change. Smaller facilities had less accounts receivable inventory available to analyze. Ratios of net revenue to facility size imply that accounts receivable ratios are properly distributed as they pertain to admission rates, total charges, and patient types. Accounts with payment percentages of 50% or greater are less available. This limited availability in data implies that efficient processes to review and contractualize high-dollar uncollectable accounts receivable are occurring. Accounts with payment percentages of 49.99% or less are more available due to less focus on low-dollar claims. This implies that there is an opportunity to perform more review on lower dollar accounts, and suggests that Parallon is focusing on high dollar claims. Creating a process to review low dollar adjustments resulted in a reduction of 75% of Parallon’s collections department inventory.
Thresholds were originally set at account balances of a 3:1 ratio for larger versus smaller clients. Facilities with larger revenue were considered below threshold if the patient’s total account balance was 3 times that of the facilities generating smaller revenues. As a result of this process ratios have remained consistent at 3:1 but overall balance thresholds were reduced. This meant that original balance thresholds were $3000 and $1000, but were reduced to $1500 and $500 due to more efficient uncollectable accounts receivable
adjustments. Within 30 days of process implementation cash improved by 17.9% for internal clients and 13.8% for external clients. This process directly contributed to collector’s abilities to collect actual accounts receivables and cash. This eliminated uncollectable and uncontrollable accounts receivable inventory from collection’s workflow, allowing more time to collect high-dollar claims. This contributed to an overall year to date net revenue cash increase of 3%, generating a cash collection amount above facility goal for the first time within 2016.
On the basis of the clinic’s previous collections experience, Dough was able to convert billings for medical services into actual cash collections. On average, about 20% of the clinic’s patients pay immediately for services rendered. Third-party payers pay the remaining claims, with 20% of the payments made within 30 days and the 60% remainder (of total billings) paid within 60 days. For monthly budgeting purposes, 20% are assumed to be collected one month after the billing month, and 60% are assumed to be collected two months after the billing month.
While the data was collected by identifying patients with the highest medical costs, lowering medical costs was never Brenner’s goal; “he was more interested in helping people who received bad health care” (Gawande, 2011). Although a clearly defined list of action steps is not outlined in the literature (Gawande, 2011; “Jeffrey C. Brenner,” 2013; Robert Wood Johnson Foundation, 2014) Brenner clearly began by using his funds to hire a staff and increase his pool of data, identified the most vulnerable patients by health care cost and emergency room and hospital visit frequency, met with the most vulnerable patients, acquired information about all of the factors affecting the patient’s health through forming relationships, and then based on the client’s needs, utilized a custom case plan to improve the delivery of health care services to the patient (Gawande, 2011; “Jeffrey C. Brenner,” 2013; Robert Wood Johnson Foundation,
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
The purpose of financial measurement in healthcare is to provide the community with the services it needs, at a clinically acceptable level of quality, at a publicly responsive level of amenity, at the least possible cost. This is done by providing healthcare finance managers with accounting and finance information to help accomplish the purpose of the organization (Nowicki, 2015). When making accounting decisions about budgeting and inventory control, an understanding of economics, statistics, and operations research is needed. Major Financial Measures
Under the Social Security Act, it is required that hospitals report quality measures for a set of 10 indicators. If hospitals do not report quality measures to CMS there is a reduction in payments. In the hospital readmission area of investigation, OIG reviews Medicare claims in hospital readmission cases to identify trends and oversights of cases. Readmissions are cases in which the beneficiary is readmitted to the hospital less than 31 days after being discharged from the hospital. Hospitals are only entitled to one diagnosed-related group payment if there is a same-day readmission for symptoms related to prior hospital stay. Quality improvement organizations are required to review hospital readmission cases also this is to see if standard of care are met. For coded conditions as present on admission, it is required for acute hospital to report these diagnoses on Medicare claims. The OIG will review Medicare claims for types of facility or providers most frequently transferring patients to hospital
There has been a shortage of physicians, lack of inpatient beds, problems with ambulatory services, as well as not having proper methods of dealing with patient overflow, all in the past 10 years (Cummings & francescutti, 2006, p.101). The area of concern that have been worse...
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
Dr. Kutup and Mrs. Mintz should approach the Admissions and Registration Manager at South Street Hospital because of their departmental involvement with accounts receivable and payable and their management of pre-certification, pre-admission, and in...
It is very important that we utilize cost control methods in the health care field. The reason being is that about 10% of the population, usually with chronic to severe problems, use approximately 70% of the total spending (Shi, & Singh, 2008). If we didn’t monitor the costs and spending we wouldn’t be using the money efficiently. To avoid potential problems we frequently use six different cost control methods to monitor what medical services are necessary, the most cost efficient way for these services to be provided, and keep an up to date chart of the patient’s condition to offer only treatment deemed necessary.
The purpose of this case study is to investigate and bring new insight to situations and behaviors within an organization. Case studies are learning tools which utilize social science research to identify and resolve individual and organizational challenges (K. Mariama-Arthur Esq., 2015).
Obtaining consent for a treatment or procedure is extremely important in health care. It is required before a health care professional can proceed with the procedure or treatment. Pierre Dupont, a trained dentist and chiropodist, was found using experimental foot implants on unsuspecting patients. These foot implants are designed to restrict excessive joint rotation outward and creates an arch in the foot for patients who have flat feet. The foot implants used on Dupont’s patients were based off of a HyProCure model approved by Health Canada in 2006. These foot implants were used without any proof of documentation or certification. Because of Dupont’s actions, the patients now have to pay to have the implants removed by David Greenberg, who
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.
As a result, a growing number of Medicare and Medicaid recipients were transferred into capitated or fixed payment plans to save on costs, but this created a problem in the collection of data because under the fee-for-service plans Medicare was the largest payer of services provided by home health care agencies at 44 percent; Medicaid came in a close second at 38 percent; private insurance and other third-party payers made up 10 percent; and the final 8 percent came from patients who paid directly out-of-pocket. Capitated plans limit the ability to collect data on home health care services because the physician is given one flat fee per the number of patients covered regardless of how many patients he actually provides services to. This makes it difficult to document the specific services provided to the patient, thus making it difficult to justify the need to expand and modify the current program. Another reason data for home health services is so difficult to track is, Medicaid programs in fifteen states have implemented self-directed services which permit patients to coordinate their own home health services and compensate family members who provide care. The implementation of self-directed services in these fifteen states have had positive results in decreasing the amount of unmet patient’s requirements and enriching health outcomes, quality of life, and beneficiary satisfaction at a rate equivalent to that of the traditional home health agency directed service