Benchmark – Risk Management Program Analysis

The purpose of this assignment is to analyze how an organization\'s quality and improvement processes contribute to its risk management program.

This assignment builds on the Risk Management Program Analysis – Part One assignment you completed in Topic 1 of this course.

Assume that the sample risk management program you analyzed in Topic 1 was implemented and is now currently in use by your health care employer/organization. Further assume that your supervisor has asked you to create a high‐level summary brief of this new risk management program to share with a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization\'s assistance in developing their own risk management policies and procedures.

Compose a 1,250‐1,500 word summary brief that expands upon the elements you first addressed in the Topic 1 assignment. In this summary brief, address the following points regarding your health care organization and its risk management program:

1. Role of the MIPPA-Approved Accreditation Body in Evaluation of the Quality Improvement and Risk Management Processes of an Organization
An explanation of the role that the MIPPA-approved accreditation body plays in the evaluation of the quality improvement and risk management processes of an organization is comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

2. Administrative Roles Relevant to Employer-Employee-Focused Risk Management Strategies and Operational Policies
A description of the roles administrative personnel play relevant to employer-employee-focused risk management strategies and operational policies is comprehensive. The submission incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

3. Support of Patient Rights and Responsibilities by Risk Management Programs and Quality Improvement Processes
An illustration of how the rights and responsibilities of a patient are supported by risk management programs and quality improvement processes is comprehensive. The submission incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

4. Legal and Ethical Responsibilities of Health Care Professionals to Uphold Risk Management Policies and Administer Safe Health Care (C3.3)
An explanation of the legal and ethical responsibilities of health care professionals to uphold risk management policies and administer safe health care is comprehensive. The submission incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

5. How Quality Improvement Processes in a Health Care Organization Support Its Journey to Excellence
Evidence of how the quality improvement processes of a health care organization support its Journey to Excellence is comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. The level of detail is appropriate.

Analysis of a Risk Management Program in the Healthcare Setting

Part one

Risk management can be defined as the identification, prevention, and reduction of the impact of risks that can be reasonably expected to befall the organization. Organizations such as healthcare organizations are exposed to various forms or categories of risks. These range from fiscal leakages, financial penalties from regulatory bodies, litigation for medical errors and malpractice (financial settlement), loss of revenue due to incorrect billing, high employee turnover, and so on. The presence of these risks is a threat to the existence of the organization. This is because the actualization of risk may spell the end of the organization in more than one way. Benchmark – Risk Management Program Analysis .For instance, unmitigated medical errors and malpractice may result in a succession of suits that cripple the organization financially and also in terms of reputation. An organization whose reputation has been spoilt will not be able to compete in the marketplace because customers who are the patients will be afraid of consuming their services. This is the reason why risk management is an important component of the strategic objectives of any organization. It saves the organization resources, particularly fiscal resources. Many risk management programs exist, but the overriding characteristic of them all is that they must be able to detect risk early and prevent it from occurring (Infosec, 2020; NEJM Catalyst, 2018; Alam, 2016). Some of the most important risk management programs are those related to the quality of care (patient safety and practitioner certifications) as well as patient information privacy and security or HIPAA (Strategic Management Services, 2008). This paper discusses the risk management program related to claims development and submission in the context of reimbursements.

ORDER A PLAGIARISM -FREE PAPER NOW

A Summary Description of the Risk Management Plan Chosen and the Rationale

According to Strategic Management Services (2008), the process of preparing and submitting claims for reimbursement is the single most important risk area for healthcare organizations. This is because this process forms the financial lifeblood of the organization. All revenues can directly be attributed to the efficiency or otherwise of this process. A slight mistake in procedure coding or billing can result in direct financial losses or indirect losses through penalties. The specific areas that this risk management program addresses are duplicate billing, wrong procedure coding inaccurate coding, defective billing, and incorrect/ improper claims (Leon-Chisen, 2018; AHIMA, n.d.). The consequences of not controlling and mitigating these risks include several categories of regulatory fines and penalties. The rationale for choosing this particular risk management program is that it touches on the financial stability of the organization and that is where the strength of the organization lies.

Comparison of Standard Risk Management Program Administrative Steps and Processes with Those in the Example

           Risk management is a systematic process that follows well-defined steps. In other words, risk management is a science and does not just depend on happenstance. Benchmark – Risk Management Program Analysis .  There are five distinct, but interrelated steps involved in any risk management program. According to Thomas (2020), these are:

1. Risk identification

This is the first step in any risk management program. At this stage, the organization is running well without any problems threatening its existence. However, there are potential threats always lurking somewhere. It is these threats that are identified before they become a reality. For instance, several cases of incorrect coding and billing that receive warnings from the Centers for Medicare and Medicaid Services (CMS). Compared to the example, this step is specific and also has a specific goal.

2. Risk analysis

In this step, the risk identified in step 1 is analyzed further to determine its strength and likelihood of occurrence. The likely impact it may have on the organization if it happened is also underscored. The possible causative factors and mitigating factors may also be considered at this stage. It is also at this step that it is determined whether this risk is a risk that can be eliminated completely or just mitigated (some risks cannot be completely eliminated, such as the risk of a competitor). In the context of this paper, an example is the risk of penalties by the CMS which can be eliminated through proper training of coders. This step is the same as that found in the example.

3. Risk evaluation and ranking

In step III the risk is evaluated, measured, and ranked in order of severity and priority. It is in the best interest of the organization to deal with the most pressing and potentially devastating risks before considering the more mundane ones. Ranking the risks also helps with the smooth implementation of planned mitigating measures. This step is congruent with the one found in the example.  Benchmark – Risk Management Program Analysis .

4. Risk treatment 

In this fourth step, the risk is handled by way of coming up with measures that attempt to remove the threat. For instance, to remove the threat of losing revenue through incorrect procedure coding the organization may organize upskilling training on-site for its coders. This step is also congruent with that one found in the example.

5. Risk monitoring and review 

As stated above, not all threats can be eliminated. It is for this reason that after implementing mitigation measures or solutions for identified threats, it is important to monitor their progress and trajectory. This allows for the implementation of fresh mitigation measures when the threat levels rise again. For instance, some degree of billing errors is expected to remain because of the human element in data entry. However, the rates should be kept at the lowest level possible. Monitoring allows for the review of measures instituted to curb the threats. This step is also in sync with the one found in the example.

Key Regulatory Agencies and Organizations and Their Roles in the Risk Management Oversight Process

In order to effectively carry out risk management, healthcare organizations depend on the input of different organizations that play different roles in mitigating these risks. These roles can be direct or indirect by association. In the case of the risk management program chosen for this case, some of these organizations and their roles are:

1. The American Health Information and Management Association (AHIMA): The aim of this organization is to improve the quality of all medical records. It was founded in 1928 and brings together healthcare professionals whose specialty is health information management (HIM) such as coders and nurse informaticists (AHIMA, n.d.). The AHIMA certification and accreditation is important in helping with risk management associated with medical records such as billing and coding.
2. The Centers for Medicare and Medicaid Services: This is a payer organization whose role in the risk management associated with billing, coding, and claims for reimbursement cannot be overemphasized.
3. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO): This is a quality assurance organization that also gives accreditation to healthcare institutions that have shown excellence in the provision of quality healthcare services. Benchmark – Risk Management Program Analysis .The role it plays in risk management is that it serves as a deterrent to organizations that would otherwise be lax in enforcing quality improvement measures.

Risk Management Plan Compliance and Proposed Recommendations

There are specific requirements by the Medicare Improvements for Patients and Providers Act or MIPPA in terms of the processes and procedures for billing for several procedures. To a large extent, the example risk management plan is in compliance with MIPPA-approved accrediting body standards (ACR Support, 2020). This can be seen in its outlined steps and how each is expected to be implemented. The proposed recommendations to enhance, improve, and secure compliance standards include: having internal audits, and audits having the ability to identify weaknesses in the coding and billing procedures.

References

ACR Support. (2020). The Medicare Improvements for Patients and Providers Act (MIPPA). Retrieved from  https://acrsupport.acr.org/support/solutions/articles/11000068571-the-medicare-improvements-for-patients-and-providers-act-mippa-revised-12-17-2020-

Alam, A.Y. (2016). Steps in the process of risk management in healthcare. Retrieved from https://www.elynsgroup.com/journal/article/steps-in-the-process-of-risk-management-in-healthcare

American Health Information Management Association. (n.d.). American Health Information Management Association (AHIMA). Retrieved from http://www.americanehr.com/about/who_we_are/content-partners/AHIMA.aspx

Infosec. (2020). Risk management in healthcare. Retrieved from https://resources.infosecinstitute.com/risk-management-in-healthcare/#gref

NEJM Catalyst (2018). What is risk management in healthcare? Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197

Strategic Management Services. (2008). Hospital risk management program: Ten risk categories for the four-step process. Retrieved from https://www.compliance.com/resources/hospital-risk-management-program-ten-risk-categories-for-the-four-step-process/

Thomas, C. (2020). Five steps in the risk management process. Retrieved from https://www.360factors.com/blog/five-steps-of-risk-management-process/. Benchmark – Risk Management Program Analysis .

Part Two

Introduction

Risk is inherent within any settings in an organization. Therefore, risk management is very critical in an organization to minimize risk to patients, stakeholders, staff, and the organizations at large. An organization has an obligation of ensuring their activities and operations do not put its stakeholders or itself at risk of damage, financial mismanagement, and damage (LoBiondo-Wood et al., 2019). This essay presents an examination of risk management program with an aim of promoting financial stability. The program relates to claims development and submission to receive reimbursements from the payers and insurance companies (Iqbal et al., 2019). The paper will analyze role of the MIPPA-Approved accreditation body, administrative roles relevant to employer-employee risk management strategies, support of patient rights and responsibilities, legal and ethical responsibilities of healthcare professionals, quality improvement processes needed to support the organization to excellence.

Role of the MIPPA-Approved Accreditation Body

Several MIPPA approved accreditation bodies will play various roles in evaluation of quality improvement initiative and risk management process. They include American Health Information and Management Association (AHIMA), Centre for Medicare and Medicaid Services (CMS), and Joint Commission on Accreditation of Healthcare Organizations. The AHIMA specializes in certifying and accrediting health information management organizations with a bid of improving quality of health records. AHIMA will help with risk associated with coding and billing (Allen-Duck et al., 2017). CMS is an organization responsible for reimbursement of claims and will be critical in risk management associated with claims development and submissions.  The Joint Commission will play an important role in provision of performance improvement measures that will help the healthcare institution to continually improve quality of health records coding and billing (Allen-Duck et al., 2017).Benchmark – Risk Management Program Analysis .   The Commission is responsible for evaluation of healthcare institutions by carrying out face-face interviews, data analytics, and observations to examine if necessary regulations are adhered (Allen-Duck et al., 2017). The commission certifies programs and healthcare institutions and will therefore have a duty of assessing the implemented claims development and submission program. In addition, the Commission will monitor and track performance of the program by issuing reports and integrating quality measures.

The Joint Commission formulates approaches to review best practices in healthcare to improve organizational management and patient care. It also establishes partnerships with experts in determination of quality measures and formulation of performance standards to act as a guideline for quality improvement (Allen-Duck et al., 2017). The health facility will report improvements achieved by the risk program to the Joint Commission and ensure it complies with the Commission’s standardized processes. The organization will submit the risk program’s annual reports and periodic performance reviews. All stakeholders involved in the claims submission risk program will be required to work as a team to pinpoint features that portray best evidence-based practices as well as coming up with strategies to improve weak areas in the program.

Administrative Roles Played by Different Level of Staff

Risk program implementation involve input of different administrative staff to ensure its success and accomplishment of intended objectives. Healthcare policies, regulations, and standards are critical in the ascertainment of adherence to set standards by staff members and improvement of strategic measures taking to safeguard financial stability of the organization. Administrative staff members have an obligation to formulate and apply policies that will ensure that employees follow established standard operating procedures and practices (LoBiondo-Wood et al., 2019). Benchmark – Risk Management Program Analysis .The formulated policies provide employees with all the information needed to promote adherence to legal responsibilities and financial responsibility and stability (Allen-Duck et al., 2017). The managers and risk management professionals have a role in formulating procedures and policies that can help in alleviating risks by promoting proper record keeping of medical records, billing and coding to avoid financial losses. In addition, administrative staff have a duty to monitor and evaluate adherence to set standards and procedures.

Support of Patient Rights and Responsibilities by Risk Management Programs and Quality Improvement Processes

Patients have right to quality care and therefore, it is the obligation of an organization to formulate quality improvement programs to support patients’ right to quality. For instance, claims development and submission risk management program will reduce errors done during coding and  billing which lead to financial losses, instability, and penalties. Financial losses and instability affects the ability of an organization to provide quality care and safety. Therefore, implementation of the risk program will improve quality of care for patients. Iqbal et al (2019) noted that implementation of risk management programs protects patients’ safety, enhance high organizational performance and adherence to set standards.  The program implementation touches on patients’ medical records and information that is used in claim submission.  A patient has a right to privacy and to have their confidential information protected. The organization has an obligation to safeguard and protect patients’ records from unauthorized access.

ORDER A PLAGIARISM -FREE PAPER NOW

Legal and Ethical Responsibilities of Health Care Professionals

Health providers have a legal and an ethical obligation to provide quality care and adhere to standard operating procedures. Healthcare professionals must maintain trust and medical ethics at all times (Kadivar et al., 2017). Benchmark – Risk Management Program Analysis . Risk management programs are implemented to improve quality and organizational performance. Health practitioners have a duty of conforming to risk management policies to mitigate against financial losses and improve quality of services offered. Employees are obligated to follow organizational policies regarding medical claims billing and coding to minimize errors, penalties, and finances that result in financial losses. Minimizing risks to patients’ amounts to good practices that ensure staff involved in claims submission monitor any adverse effects and work within set systems and standards to minimize the occurrence of errors. Kadivar et al (2017) noted that healthcare professionals are required to have requisite knowledge and skills to provide quality services at their relevant work stations. Therefore, health professionals are legally obligated have adequate competence for effective performance of duty.

Quality Improvement Processes Impact to Organization

Quality improvement processes and risk management programs play a significant role in organizational performance and success. Risk management programs often result in better outcomes which enhance quality of care and client satisfaction. When an organization has a program to mitigate risk of financial loss, it improves its financial stability, service delivery and its clients are more likely to return for services in future or make referrals (Iqbal et al., 2019). Through quality improvement processes, health organizations are able to make profits by maintaining clients’ volume and earn a competitive advantage in the market. An organization that initiates and implements risk management programs is aware of its weaknesses, works towards improving the negative attributes and avoid litigation that emanate from inaccurate billing and coding (LoBiondo-Wood et al.,2019). Quality improvement processes enable an organization to improve on the quality of care, reduce medical errors, and address patients’ needs (Allen-Duck et al., 2017).Benchmark – Risk Management Program Analysis .   Through risk and quality management programs, organizations have been able to adhere to regulatory requirements and avoid fines and penalties emanating from lack of adherence. Adherence to set standards and complying with standards sets by regulatory bodies has enabled the organization to be positively rated thereby improving its reputation.

Conclusion

It is the duty of organizations to provide patients and all stakeholders with quality services. To maintain quality standards, it is necessary to initiate quality improvement processes and risk management programs to ensure continuous improvement of organizational performance, service delivery and client satisfaction. Benchmark – Risk Management Program Analysis .

References

Allen-Duck, A., Robinson, J. C., & Stewart, M. W. (2017). Healthcare Quality: A Concept Analysis. Nursing Forum, 52(4), 377–386. doi:10.1111/nuf.12207.

Iqbal, U., Humayun, A., & Li, Y. C. J. (2019). Healthcare quality-improvement and measurement strategies and its challenges ahead. International Journal for Quality in Health Care.

Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical and legal aspects of patient’s safety: a clinical case report. Journal of medical ethics and history of medicine, 10, 15.

LoBiondo-Wood, G., Haber, J., & Titler, M. G. (2018). Evidence-Based Practice for Nursing and Healthcare Quality Improvement-E-Book. Elsevier Health Sciences. Benchmark – Risk Management Program Analysis.