HIM 510 Module 9 Final Project Example

Final Project: A Revenue Management Package and a Professional Identity Statement for Laurel Point

[Student Name]

Southern New Hampshire University

HIM 510: HIM Applications and Systems

Final Project

[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: A Revenue Management Package and a Professional Identity Statement for Laurel Point

Part I: The Revenue Management Package

This package asks Laurel Point Regional Medical Center's leadership to approve policy RC-100, Revenue Management and Revenue Integrity, with four supporting procedures. It brings together the course's revenue cycle assessment, policy statement and procedures, revised in light of feedback from the compliance officer, the patient access director and course review.

What the Assessment Found

Laurel Point loses revenue at every stage of the cycle. Initial denials run at 11.8%, up from 8.9% two years ago, and only 82% of claims pass edits cleanly. Discharged accounts wait 6.1 days to be billed. Nearly half of denials trace to the front end, with missing authorizations alone causing 31%; medical necessity disputes cause 22% and are rising with Medicare Advantage volume, and coding errors cause 14%. Payers reverse 47% of the denials the hospital appeals, a sign that many should never have been issued or could have been prevented. Schwartz et al. (2022) showed that private Medicare plans often apply coverage rules beyond traditional Medicare's, which explains part of the growth in necessity denials.

The Policy and Procedures in Brief

Policy RC-100 sets six commitments: verify authorization before scheduled services, document medical necessity to payer criteria, code only from documentation and guidelines, query compliantly, work denials within five business days and never bill patients for the hospital's own errors. Four procedures carry it out: authorization verification owned by patient access, denial triage owned by patient financial services, appeals supported by health information management and medical necessity review owned by clinical documentation integrity. Each procedure has an owner, steps, timing, records and a monitoring measure.

Revisions Made After Feedback

Three revisions strengthen the package. The compliance officer asked that emergency services be explicitly exempt from pre-service authorization, and the policy now states that emergency care is never delayed for insurance verification. The patient access director noted that five business days was too short to obtain some authorizations for complex imaging, so the procedure now allows a documented exception with clinician approval. And course feedback pointed out that the original draft measured denial rates but not patient effects, so a measure now tracks patient complaints and balances transferred to patients after denials.

Rollout and Expected Results

Table 1 shows the twelve-month rollout and the results expected by its end.

Table 1. Rollout and Expected Results

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

Risks

Three risks could limit results. Staffing turnover in patient access could undermine authorization work, so the package includes role-specific training that new staff complete before working independently. Payers may change criteria faster than documentation guidance is updated, which the medical necessity procedure addresses with quarterly criteria reviews. And pressure to improve revenue could drift toward coding, which the policy's coding neutrality commitment and the compliance office's review of initiatives are designed to prevent.

What Leaders Are Asked to Decide

Leadership is asked for four decisions. First, approve policy RC-100 as a hospital-wide policy with the chief financial officer and compliance committee as joint owners. Second, fund two additional authorization specialists, the largest new cost in the package, estimated at $128,000 a year, which the expected reduction in authorization denials should repay within the first year. Third, direct the medical executive committee to review the medical necessity documentation guidance so that physicians see it as a clinical tool rather than a billing demand. Fourth, agree that monthly revenue integrity reports will include the patient measures alongside the financial ones, so that the hospital judges success by both.

Part II: Professional Identity Statement

I am a health information professional, and my first commitment is to the accuracy and integrity of the health record, because every other use of health information, from care to payment to research, depends on it. Cruess et al. (2015) describe professional identity as formed over time through experience and community until a profession's values become one's own. This course tested mine. When revenue pressure arrived, I found that my answer did not come from policy alone but from what I believe my profession is for.

I hold four values. Accuracy: I code and report what the documentation supports, no more and no less, knowing that research such as Dafny (2005) shows how payment incentives can pull coding upward when no one holds the line. Fairness to patients: Kyle and Frakt (2021) describe the time and stress that administrative failures impose on patients, and I will not let the hospital's errors become their bills. Lawful stewardship: I share information only as the law and the patient's rights allow, and only as much as the purpose requires. Collaboration: revenue and records are shared processes, so I lead by building agreements with patient access, clinicians, finance and compliance rather than working alone.

How These Values Guide My Work

These values translate into commitments I can be held to. I will support revenue goals through better documentation, clearer processes and faster appeals, not through coding pressure. I will make sure staff who refuse to code or release information improperly are protected. I will measure the effects of revenue work on patients as well as on the balance sheet. And I will keep learning, especially in data analytics, payer policy and the governance of automated coding tools, because the systems that carry health information keep changing. In the roles I expect to hold, as a revenue integrity manager and later as a health information director, these commitments will be the standard I use when a decision is hard.

References

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2015). A schematic representation of the professional identity formation and socialization of medical students and residents: A guide for medical educators. Academic Medicine, 90(6), 718-725. https://doi.org/10.1097/ACM.0000000000000700

Dafny, L. S. (2005). How do hospitals respond to price changes? American Economic Review, 95(5), 1525-1547. https://doi.org/10.1257/000282805775014236

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