Component Of The Effective Compliance Program In The Hospital Setting

There are several different roles within the hospital setting for patient access services. The patient access services are responsible for the revenue cycle as well as any regulatory issues and maintaining patient safety (2011). The patient access services responsibilities include customer service, positive identification of patients, determining special needs of patients, pre-admission services, scheduling of services for patients, pre-certification for insurance, determining correct level of care for patients, obtaining signatures on documents, infection control, complete and accurate collection of patient information and point of service collections (2011). With the patient access services doing all these jobs this provides correct and accurate information for billing purposes and results in timely claims for reimbursement without penalties. Patient financial services handles all processing of bills, posting payments, correcting any claims that are denied, appeals and denials that may be incorrect, give any additional documentation if needed and make corrections if needed.

The first step in making sure this is all correct is verifying the patient’s insurance and that they are eligible for services. Next would be obtaining and prior authorizations or precertification’s for any procedures. Some instances patients are required to pay up front before they are seen, and this is known as point-of-service collections. The third-party will then review the claims that have been submitted to see if the services rendered were out of medical necessity. The third party will then decide to either reimburse for the services rendered or deny the claim. The key areas of review are patient access, reduction of denials with accurate information, employ eligibility tools, increase visibility into patient’s responsibility, checking the patient’s propensity to pay, collecting fees before care, and financial triage strategies.

The hospitals nonpayment risk can be reduced with patient access. To help increase cash flow and reduce accounts receivables there are several things that can be done including gauging whether the patient is able to pay by running their propensity to pay and collecting part of the fee for service before being seen. A way to structure the follow-up staff for effectiveness would be to make follow up calls to patients that have been recently discharged. Once the staff makes a call they would document in the patient’s chart that they called and the reason for the call. The staff could make follow-up calls regarding post discharge instructions and make sure that the patient is doing well and has no concerns. The staff could also inquire about the status if their health since discharge or ask them if there are any other questions or concerns. This would be an effective follow-up method because there would be documentation in the patients chart as to who called and why they called.

For an effective compliance program there are seven steps to follow. The steps are as follows, implement written policies, procedures and standards of conduct, designation of a compliance officer and compliance committee for program oversight, establishment of reporting systems to encourage individuals to make complaints regarding compliance, commitment to conducting formal education and training programs for employees, ongoing auditing and monitoring of systems to access the effectiveness of the compliance programs, development of policies to enforce standards of conduct with disciplinary actions for employees and corrective actions to be conducted when necessary. There are several key aspects to look at when negotiating a managed care contract. One of them being whether it will be a one-time negotiation or a long-term deal. Also, when negotiating they want to look at rates and make sure they are getting a fair deal for services. Along with rates you must look at what the hospital has to offer and what they provide and whether they have other entities included. Once this has all been done organizations need to sit down to make a comprehensive payor profile which will tell each of them what they would both like out of this negotiation. Managed care contracts impact reimbursement daily. Managed care contracts play a huge role in the financial strategy of the healthcare organization.

Healthcare revenue is a large amount from managed care dollars. Paula Dillon states that “Strong managed care contracts can also enhance patient satisfaction because they facilitate patient access to comprehensive treatment and services”. Managed care plans and the reimbursement system provide incentives to providers and hospitals to reduce healthcare costs. By providing these incentives to hospitals and providers better care is given to patients and there is more access to care for these patients. Besides the incentives there are also guidelines to follow to receive those incentives. This improves the reimbursement for the hospital’s organization by following these guidelines because it cuts down on claim denial among other things.

There are several rules and guidelines for billing and coding compliance. If these guidelines are not followed a federal investigation could result. These guidelines have been put in place by the Health Insurance Potability and Accountability Act (HIPPA), the Office of the Inspector General (OIG) and the Healthcare Reform Act of 2010 (2018). The first guideline is being HIPPA compliant, which includes all patient information such as gathering, cataloging and transferring of this information. This is divided into titles with the first being Healthcare Access, Portability, and Renewability. With this it looks at how health insurance companies treat people with pre-existing conditions. The second is Preventing Medical Healthcare Fraud and Abuse, Administrative Simplification, and Medical Liability Reform. This title is more to concerns relating to the coding and billing field who handle the patients medical record.

The most common fraudulent practices the OIG deals with are unbundling codes, upcoding, under coding and falsifying medical records. If any of this is suspected an audit will be performed and if further measures are needed a federal investigation will take place.