Abstract
I want to start my report by explaining the essential factors of our financial management. Our hospital utilizes diagnosis classification to evaluate the costs of medical servicing. We operate under the most widespread and commonly implemented system, which peruses diagnosis-related groups. Funding of a particular patient depends on the severity of the case that the hospital assesses. We affiliate patients with comparable clinical characteristics to one financial group, which needs similar resource-utilization, consequently, analogous funding. The affiliation is primarily based on:
- age group;
- comorbidity level;
- flagged interventions;
- intervention events;
- out-of-hospital intervention.
In this regard, I want to draw your attention to the technical side of our financial management. Our hospital peruses CureMed billing software. The features implemented in the program are pretty vast, so our employees utilize CureMed as a database through which we process all payments, confirm insurances, analyze patients’ emails, and submit claims for reimbursement, and more.
Now, I would like to explain what care reimbursement entangles. Medicare funds our center. Additionally, our patients have different expenses plans offered by their health insurance providers. Once admitted to our center, our clients are affiliated with one of the diagnosis-related groups. At this stage, we inform their insurance provider about the estimated costs of medical care. As may already suspect, the diagnosis system takes different variables into account, so classification is not void of possible mistakes (Sorensen & Burau, 2016). We may assign a “higher” level of severity. Consequently, unspent funds remain at the hospital. Contrariwise, it may be possible for our center to underestimate the diagnosis of a particular patient, so we request lesser funds than needed and cover further expenses from our budget.
Violations in Costs of Medical Care
Our hospital has been inspected for any billing violations, and we are presented with an unfavorable report, which detects severe mistakes that must be taken into consideration and immediately amended. We have caught several cases of duplicate billing caused by the fact that caregivers and doctors issued a bill for the same service due to overflowing data in our database and lack of structure on prescribed interventions and medication. Additionally, we have tracked instances of upcoding, where the highest level of services was assigned to patients, and subsequently, they were charged more than they should have been due to their clinical record. These cases entangle another billing violation: phantom charges, additional expenses levied from patients’ care reimbursement for service services that were not needed. Consequently, they were not provided. Due to partial staff’s negligence, some patients have been prescribed a higher dose of medicine than was required for their condition. In this regard, we have to report incorrect quantities of prescribed medication that resulted in the upcharge of our clients.
A Contingency Plan for Overcoming Crisis
The report has shown that we must reinvestigate our financial management, arrange compensation for the affected patients, and reorganize our system to fit in the requirements of a respectful, compassionate, and just medical organization. To achieve that, we must:
- Upgrade the current diagnosis classification system to eliminate possible system failures and prevent unintentional upcoding and incorrect quantities of prescribed medication (Sorensen & Burau, 2016).
- Make improvements to our operating software and CRM programs to eliminate possible data duplication and subsequent duplicate billing.
- Introduce new training to accommodate our staff on implemented changes and make the transition as comfortable as possible in the given circumstances. To lessen strategic pressure points, we would organize support groups where employees could address their worries and relieve stress from changing the working environment. This practice will subsequently strengthen internal communication, which also assists in our aim to reduce the number of medical errors.
- Reshape our budget and funding to accommodate the needs of affected clients. In this regard, we have agreed on introducing advance care planning (Stuart, et. al., 2017) and cost-sharing practices (Perkowski & Rodberg, 2016).
Advance care planning is primarily based on our patient’s preferences, so it is partially related to evidence-based practices in nursing. The planning in question may prevent implementing potentially ineffective, which, in its turn, may result in higher cost-effectiveness. We address a comprehensive process, which involves communicating between patients, caregivers, and our clinicians (Stuart, et. al., 2017). We believe that this practice becomes one of many to come that evokes a higher level of communication. Our hospital aims to advance this aspect on both client-clinician and clinician-clinician levels. As for cost-sharing practices, we are determined to analyze a current prescribed intervention system to eliminate ineffective procedures to decrease possible expenditures. For this expenses plan, we will introduce the strategy of copayments, coinsurance, and deductibles (Perkowski & Rodberg, 2016).. We believe the practice will make payment procedures more predictable and transparent, resulting in a lesser medical upcharge.
The inspection has detected flaws in our system, and our hospital aims to amend them to enhance medical service. Altogether, we are set on implementing a new comprehensive approach to HR and financial management, which would prove beneficial to our patients. We strive to arrange the best care, which results in fewer readmissions. With advance care planning and cost-sharing plans, we will be enabled to prioritize our patients’ values and preferences. Therefore, the contingency plan in question will mitigate the risks of a potential crisis in the future.
References
CMG+.
Perkowski, P., & Rodberg, L. (2016). Cost Sharing, Health Care Expenditures, and Utilization: An International Comparison. International Journal of Health Services, 46(1), 106-123.
Sørensen, M., & Burau, V. (2016). Why we need to move beyond diagnosis-related groups and how we might do so. Journal of Health Services Research & Policy, 21(1), 64-66.
Stuart, B., Volandes, A., & Moulton, B. (2017). Advance Care Planning: Ensuring Patients’ Preferences Govern the Care They Receive. Generations: Journal of the American Society on Aging, 41(1), 31-36.