Real$-$World Case: Chapter $8$

$1.$ Paradise Pier Hospital has received a number of payer denials for services billed with incorrect CPT codes and revenue codes. After investigating, Elizabeth discovered several departments were submitting their charges using electronic source systems or paper charge tickets that had not been updated to match the billing system$$s charge master.

a$.$ Discuss what Elizabeth should do to correct this problem and measures that should be put in place to ensure the CDM is correct and electronic source systems and paper charge tickets are updated appropriately.

$2.$ The director of revenue integrity at Marceline University Health System has examined several benchmarks for denial key performance indicators $($KPIs$).$ The director discovers the organization deviates significantly from the overall initial denials rate, which has recently reached $9\%$ of Health System$$s gross revenue. The identified best practice KPI for initial denials is $<=4\%$ of gross revenues.

a$.$ Why is it important for the organization to achieve that particular KPI metric?

b$.$ What areas of the revenue cycle are affected by deviation from the metric, and what are the impacts on those areas?

c$.$ What steps would you take to improve processes and achieve the KPI metric?

d$.$ Identify the areas that would need representation to work on the process improvement plan

e$.$ Once the improvement efforts resulted in achieving the metric, how would you ensure sustained results?