HIM 510 Module 5 Final Project Milestone Two Example

Final Project Milestone Two: A Revenue Management Policy for Laurel Point Regional Medical Center

[Student Name]

Southern New Hampshire University

HIM 510: HIM Applications and Systems

Final Project Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Final Project Milestone Two: A Revenue Management Policy for Laurel Point Regional Medical Center

Rationale

Milestone One showed that Laurel Point's denials come from every stage of the revenue cycle: authorization and eligibility errors at the front end, medical necessity and coding problems in the middle and slow appeals at the back end. No single department can fix them, and no department currently owns the whole process. A hospital-wide policy can assign responsibility, set standards and require measurement, while keeping revenue work within compliance. The policy below has six commitments, each tied to a finding.

Three findings shaped the commitments most. Schwartz et al. (2022) showed that private Medicare Advantage insurers often apply medical necessity criteria that differ from traditional Medicare's, which is why the policy requires payer-specific documentation guidance. O'Malley et al. (2005) located sources of coding error all along the path from what clinicians write to what coders assign, which is why accuracy is framed as a shared responsibility rather than a coding task. Finally, Kyle and Frakt (2021) described the administrative burden that billing problems place on patients, which is why the policy commits the hospital to resolving its own errors before billing patients.

Policy Title and Identifiers

Revenue Management and Revenue Integrity. Policy number RC-100. Owner: Director of Revenue Integrity. Approved by: Chief Financial Officer and Compliance Committee. Applies to all inpatient and outpatient services billed by Laurel Point Regional Medical Center. Effective upon approval; reviewed annually.

Purpose

This policy establishes Laurel Point's standards for obtaining, documenting, coding, billing and collecting payment for services accurately, promptly and in compliance with law, payer contracts and official coding guidelines. It aims to reduce preventable denials, protect patients from avoidable administrative burden and ensure that revenue reflects the care actually provided and documented.

Scope

The policy applies to patient access, clinical staff who document care, clinical documentation integrity, health information management, charge capture staff, patient financial services, compliance and contracted billing vendors. It covers all payers, including government programs, Medicare Advantage and commercial plans, and all hospital-billed services.

Policy Statement

Laurel Point will observe six commitments. First, required authorizations and eligibility will be verified and documented before scheduled services, except in emergencies. Second, clinical documentation will support the medical necessity of services, using payer-specific guidance maintained by clinical documentation integrity. Third, diagnoses and procedures will be coded according to official guidelines and documentation only; coding will never be directed toward a desired payment. Fourth, questions to clinicians about documentation will follow compliant query practice. Fifth, denials will be reviewed within five business days and appealed when documentation supports the service. Sixth, the hospital will correct its own errors before billing patients, and patients will not be billed for amounts owed because of a hospital authorization or registration error.

Definitions

Table 1 defines key terms used in the policy.

Table 1. Definitions

Note. Definitions drafted by the author.

Responsibilities

Patient access verifies eligibility and obtains authorizations, documenting them in the record where clinicians and billing staff can see them. Clinicians document the reasons for services and respond to queries within two business days. Clinical documentation integrity maintains payer-specific documentation guidance and reviews high-risk services before billing. Health information management codes accurately, completes records promptly, audits coding quarterly and supplies records for appeals. Patient financial services submits claims, works denials within five business days and coordinates appeals. The compliance office reviews revenue initiatives before launch, audits query practice and receives reports of concerns without retaliation. The Director of Revenue Integrity coordinates across departments and reports measures monthly.

Exceptions

The authorization commitment does not apply to emergency services, which must never be delayed for insurance verification under federal emergency care law; authorization for emergency admissions will be pursued after stabilization. Services ordered during an inpatient stay that could not reasonably be authorized in advance will follow payer notification rules instead. Any other exception to this policy requires written approval from the Director of Revenue Integrity and the compliance officer, with the reason documented and reported to the revenue cycle committee.

Measures and Review

Compliance with the policy will be measured monthly by the initial denial rate, the preventable denial rate, the clean claim rate, days awaiting final billing, coding accuracy from quarterly audits and the appeal overturn rate. Results will be reported to the revenue cycle committee monthly and to the compliance committee quarterly. The policy will be reviewed annually and whenever payer rules or regulations change significantly.

Enforcement

Departments that repeatedly miss the standards in this policy will develop corrective action plans reviewed by the revenue cycle committee. Individual performance concerns will be handled through normal supervisory channels with a focus on training and process fixes before discipline. No employee will be disciplined for refusing to code, document or bill in a way that conflicts with this policy, official guidelines or law, and concerns may be raised through the compliance hotline without retaliation.

Related Documents

This policy relates to the hospital's coding compliance policy, clinical documentation integrity query policy, patient financial assistance policy and record release policy. Procedures carrying out this policy will be issued separately, beginning with denial management, pre-service authorization and appeal procedures in Milestone Three.

Design Notes

Two design choices deserve explanation. The policy places patient protection among its commitments, not only in the patient financial assistance policy, because denials caused by the hospital should never become the patient's problem. And it names coding neutrality explicitly, so that any future revenue initiative that pressures coding would visibly conflict with approved policy, giving coders and compliance staff a clear basis to object.

References

Kyle, M. A., & Frakt, A. B. (2021). Patient administrative burden in the US health care system. Health Services Research, 56(5), 755-765. https://doi.org/10.1111/1475-6773.13861

O'Malley, K. J., Cook, K. F., Price, M. D., Wildes, K. R., Hurdle, J. F., & Ashton, C. M. (2005). Measuring diagnoses: ICD code accuracy. Health Services Research, 40(5, Pt. 2), 1620-1639. https://doi.org/10.1111/j.1475-6773.2005.00444.x

Schwartz, A. L., Chen, Y., Jagmin, C. L., Verbrugge, D. J., Brennan, T. A., Groeneveld, P. W., & Newhouse, J. P. (2022). Coverage denials: Government and private insurer policies for medical necessity in Medicare. Health Affairs, 41(1), 120-128. https://doi.org/10.1377/hlthaff.2021.01054