Discussion 7 responses

When responding to your classmates, examine the control mechanisms they identified. Compare and contrast those mechanisms with the ones you chose and discuss how either control mechanism may be modified to be more efficient.

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Response # 1

    To increase our capability to track reimbursed CMS claims I would create claims management key performance indicators (KPI’s) that track both the number of clean claims (Quickly accepted claims) and the number of claims denials. (LaPointe, 2017) It will be essential to review current KPI’s then update to use KPI’s that are specific to tracking reimbursed claims. This will improve benchmarking data collected to enable tailored staff training and process improvement where it is most needed.

     CMS uses a system called the Medicare Administrative Contractor (MAC) for claims submissions, which uses an outpatient code editor (OCE) that is available to administrators to help them to increase their clean claims rate. (Castro, 2018)

    I would also implement a work group that concentrates on reimbursed claims tracking that would prepare and review data reports and develop strategies for improvement. They would update staff of their findings and suggestions for improvement at monthly meetings.


     Castro, A.B. (2018) Principles of healthcare reimbursement. American Health Information Management Association. Chicago, IL. ISBN: 978-1-58426-646-4

     LaPointe, J. (2017, Mar 17) Tracking key hospital revenue cycle metrics to up profitability. Retrieved from: https:// www.revcycleintelligence.com/news/tracking-key-hospital-revenue-cycle-metrics-to-up-profitability

Response # 2

Medicare reimbursement rates are driven through CMS and are categorized within the Prospective Payment System (PPS).  The PPS determines payment based on a predetermined/fixed amount for a particular service that is derived based on the classification system of that service (“Prospective Payment Systems,” 2019).   CMS updates this classification system often.  As a hospital administrator, it is vital to understand this classification system to ensure documentation is being completed appropriately before submission/billing to Medicare.  Claims that are submitted to Medicare contain visit information, patient information, facility information, and detailed charges by procedure code, and diagnosis codes (Castro, 2018, p. 166).  Knowledge of CPT codes and ICD-10 diagnostic/procedural coding is critical.  Incorrect code identification can result in delayed reimbursement or denial of payment.  Payment determination is also specific to what type of service the facility is billing for. For example, outpatient services may be billed differently than inpatient services.  Each service could have specific exceptions or outliers that affect payment and billing requirements.  Specific standards and certifications must be met by the facility to remain compliant. 

Tracking reimbursed claims is a way to ensure the facility is receiving payment for services that are provided.  This can be cumbersome for a facility, as billing/reimbursement can be a difficult process that changes from payer to payer.  At a facility-based level, a hospital administrator can establish protocols and guidelines to ensure key players are tracking claims and logging reimbursements.  Specific reimbursement targets must be tracked.  O’Connor (2015) notes that a facility can maintain/update patient files, ensure training programs are in place that promote access to filing requirements/expedite processing, establish a system to track denials, enhance quality control, and ensure follow-up on delinquent claims takes place.  This information should be tracked daily at the facility within the utilization review department.  Key performance indicators should be monitored via the use of a departmental dashboard.  Daily updates on any potential hiccups with claim submissions, delays in reimbursement, or denials should be communicated in morning leadership meetings.  This information should also be shared with any corporate overseer, as billing and claim submission may involve a larger accounts receivable department.  The facility should also utilize additional resources established through specific governmental agencies.  CMS and Medicare have established various protocols that providers can utilize to track claim status.  Providers can enter data via the Interactive Voice Response telephone system operated by the Medicare Administrative Contractors, can submit claim status inquiries via internet-based portals, and can send a Health Care Claim Status Request electronically to receive a response directly from Medicare (“Claim Status Request,” 2019).  If it becomes a concern that reimbursements are being withheld or claims are being denied, the facility should immediately inquire about additional services/programs offered through Medicare to help the facility. Medicare developed the Targeted Probe and Educate (TPE) program which is defined as a process that can be utilized by those who have high denial rates/unusual billing practices to help the facility remediate common errors in submissions to help improve chart accuracy and secure payment (“Improving the Medicare,” 2020). 


Castro, A. (2018). Principles of Healthcare Reimbursement (6th ed.). Retrieved from https://mbsdirect.vitalsource.com/#/books/9781584266648/cfi/6/8!/4/2/2/[email protected]:0

Claim Status Request and Response. (2019). Retrieved from https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ClaimStatus

Improving the Medicare Claims Review Process. (2020). Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/What_Is_TPE-Infosheet.pdf

O’Connor, S. (2015). 5 ways to improve your medical claims billing process. Retrieved from https://www.adsc.com/blog/5-ways-to-improve-your-medical-claims-billing-process

Prospective Payment Systems. (2019). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen

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