Informatic Fundamentals

Principles of Healthcare Reimbursement and Revenue Cycle Management Student Workbook

Chapter 13

Advanced Exercises

1. Denials Management Dashboard (Level 6—Creating)

Denial management is a key function of revenue integrity. To begin to understand why denials are occurring, denial management teams track denials and then utilize dashboards or trending reports to assist with root cause analysis. In this assignment groups create a denials management dashboard.

Create a system (spreadsheet or other tool) to track denials. Data elements that should be included in the system are:

a. Encounter identifier

b. Payer

c. Denial type

d. Date of denial

e. Total charges

f. Amount denied

g. Denial reason (create categories,e.g., coding error, clinical validation)

h. If appeal was initiated

i. Amount recovered

j. Additional elements students wish to include

Once you have created your tracking tool, populate it with 20 denied claims (all for the month of January 202X. You will populate your tool with fictious data. Try to create real-world scenarios for the 20 cases. Before you prepare your scenarios, review the information that is required for the dashboard portion of this assignment. For example, “top denial reasons by payer” is a metric; therefore, you should include three to four different payers within your 20 scenarios so you can populate this metric. Additionally, review information in the textbook to help you determine denial types and denial reasons.

Using the information you prepared and enteredin tracking tool, create a dashboard for January 202X. Again, you will create fictious data to populate your dashboard and report (i.e., patient service revenue). The metrics to include are:

a. Denial rate

b. Denial write-offs as a percentage of net patient service revenue

c. Top denial reasons by payer

d. Appeal success rate

2. Summarizing Medicare Compliance Documents (Level 6—Creating)

As a leader and manager, the health information administrator is responsible for communicating compliance requirements and regulations. This responsibility requires the manager to interpret compliance guidance documents, relate requirements to hospital-specific operations, create a plan of action, and execute the plan.

Go to the Medicare National Coverage Determinations Manual (Publication #100-03) located at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS014961. There are four parts to the manual and numerous sections. Review the table of contents and pick anNDC to use for this assignment. It would be wise to choose a topic that is of interest to you or that you know some information about. For example, if you have a family member with diabetes, you may be interested in #100.14, Surgery for Diabetes.

You are a data analyst at Memorial Hospital.You have been charged with preparing an educational session about the NCD because your facility has been receiving denials for this service.

Your educational session will be a self-guided slide deck presentation. Your slides should be formatted so that the viewer can obtain all information from the slides with or without a voice-over (i.e., the viewer is reading the slides). Your session should contain all pertinent information about the coverage or noncoverage for the service you have chosen.

Note: This is a Reimbursement assignment.

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