HIM 510 Module 7 Final Project Milestone Three Example

Final Project Milestone Three: From Policy to Practice, Four Revenue Procedures for Laurel Point

[Student Name]

Southern New Hampshire University

HIM 510: HIM Applications and Systems

Final Project Milestone Three

[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 Three: From Policy to Practice, Four Revenue Procedures for Laurel Point

Policy RC-100 commits Laurel Point Regional Medical Center to verifying authorization before scheduled services, supporting medical necessity in documentation, coding neutrally, querying compliantly, working denials within five business days and never billing patients for the hospital's own errors. A policy changes nothing until staff know exactly what to do. Written procedures also protect staff, because an employee who follows a documented procedure can show that a decision was made the approved way, and they give auditors a standard to test against. This milestone writes four procedures for the areas that caused most denials in the Milestone One review, each in a consistent format that staff can follow and auditors can check.

Procedure RC-100.1: Pre-Service Authorization Verification

Purpose: prevent denials for missing authorization, which caused 31% of denials in the review. Owner: patient access supervisor. Steps: (1) At scheduling, the scheduler checks the payer's authorization requirements for the service using the payer rules tool. (2) If authorization is required, the authorization specialist requests it at least five business days before the service and records the reference number, dates and approved units in the encounter. (3) Two business days before service, the specialist confirms the authorization is approved; if not, the specialist notifies the ordering clinician and the patient and reschedules unless the clinician documents urgency. (4) On the day of service, registration confirms the authorization is attached. Records: authorization details stored in the encounter, visible to clinicians and billing staff.

Procedure RC-100.2: Denial Triage

Purpose: ensure every denial is reviewed and routed within five business days. Owner: denial management lead in patient financial services. Steps: (1) Each business day, the lead reviews new denials from remittance files. (2) Each denial is assigned a root cause code from a standard list: authorization, eligibility, medical necessity, coding, timely filing, duplicate or other. (3) The denial is routed to the responsible department: patient access for authorization and eligibility, clinical documentation integrity for medical necessity, health information management for coding and patient financial services for the rest. (4) The receiving department decides within three business days whether to correct and resubmit, appeal or write off, documenting the reason. (5) Write-offs caused by hospital error are coded as such and never transferred to patient responsibility. Records: denial log with root cause, owner, decision and dates.

Procedure RC-100.3: Appeals

Purpose: appeal supportable denials promptly with the right records and no more. Owner: appeals coordinator, with health information management providing records. Steps: (1) The coordinator confirms the payer's appeal deadline and level; for Medicare, the first-level redetermination request must be filed within 120 days of the initial determination, and commercial deadlines vary by contract. (2) Health information management assembles the record set defined for the denial type, following the minimum necessary protocols adopted in Module Six, and excludes psychotherapy notes and protected substance use disorder records unless authorized. (3) The coordinator writes an appeal letter citing the documentation and the payer's own criteria. (4) The appeal is sent through the payer's secure portal when available and logged. (5) Outcomes are recorded, and overturned denials are reviewed monthly to identify payers or services that deny inappropriately. Records: appeal file with letter, record set, submission confirmation and outcome.

Procedure RC-100.4: Medical Necessity Review for High-Risk Services

Purpose: ensure documentation supports medical necessity before billing services with frequent denials. Owner: clinical documentation integrity manager. Steps: (1) Documentation integrity maintains a list of high-risk outpatient services, such as advanced imaging and certain infusions, with each major payer's criteria. (2) The record system flags these services when ordered. (3) Before the claim is released, a documentation specialist compares the note with the payer's criteria. (4) If documentation is incomplete, the specialist sends a compliant query to the ordering clinician, presenting the criteria and clinical indicators without suggesting an answer. (5) If the clinician's response does not support necessity, the claim is billed with the appropriate notice or modifier as the payer requires, and the patient is informed in advance where rules call for it. Records: review checklist and any query retained with the encounter.

Why These Procedures

Each procedure addresses a cost the research describes. Procedure RC-100.4 keeps coverage criteria payer by payer because Schwartz et al. (2022) documented private Medicare plans layering their own requirements on top of what traditional Medicare asks. Tseng et al. (2018) showed how much staff effort billing already consumes, so the procedures aim to prevent rework rather than add review steps everywhere. Gottlieb et al. (2018) described how varied payer rules create complexity that leads to denials, which the payer rules tool in Procedure RC-100.1 is meant to absorb. Last, Kyle and Frakt (2021) documented how much time and stress insurance paperwork costs patients, and that finding is why RC-100.2 forbids shifting hospital-error write-offs to patients and RC-100.4 requires advance notice when a service may not be covered.

Training and Monitoring

Staff in each role will complete short, role-specific training before the procedures take effect, using real denied claims as examples. Table 1 shows how compliance with each procedure will be monitored.

Table 1. Monitoring Plan

Note. Targets proposed by the author for the revenue cycle committee.

Conclusion

Four procedures carry policy RC-100 into the work of patient access, patient financial services, health information management and clinical documentation integrity. Each names an owner, steps, timing and records, and each has a measure that shows whether it is followed and whether it works. Together they make the policy's commitments visible in the daily work of four departments, and they give the revenue cycle committee a way to see, month by month, whether the hospital is keeping its word to payers, to its own staff and to patients. The final project will combine the policy and procedures with a professional identity statement.

References

Gottlieb, J. D., Shapiro, A. H., & Dunn, A. (2018). The complexity of billing and paying for physician care. Health Affairs, 37(4), 619-626. https://doi.org/10.1377/hlthaff.2017.1325

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

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

Tseng, P., Kaplan, R. S., Richman, B. D., Shah, M. A., & Schulman, K. A. (2018). Administrative costs associated with physician billing and insurance-related activities at an academic health care system. JAMA, 319(7), 691-697. https://doi.org/10.1001/jama.2017.19148