1. Developing Policies and Procedures
John Behn, MPA
Laurie Daigle, CPC

2. Objectives Understand the organization expectations
Develop consistent practices and guidelines
Establish reasons and benefits of P&Ps
Understand the difference between policies and procedures
Identify processes within your revenue cycle that can benefit from, or be improved by, policies and/or procedures

3. Facility Expectations
Mission and culture
Format
Approval process
Initial
Changes
Review requirements
Understand facility or system expectations

4. Consistent Practices Research topic across departments
System-wide
Processes and expectations may vary slightly from department to department
Should not contradict other policies or procedures
Example
Policy in billing may be that employees will be considered late if clocked in more than 10 minutes after scheduled
Registration and call center may be three minutes after scheduled time
Both policies should state employees are expected to adhere to scheduled hours within department
Registration can stress the need to be available to patients

5. Considerations
All policies and procedures must adhere to hospital system expectations HR
Dress code
Flex time
Overtime requirements
ADA
Performance
Other
Compliance
HIPAA
Quality
If necessary, confirm or clarify before rolling out

6. Reasons To Implement Policies
Compliance
Promote clear understanding of expectations
Eliminate perceptions of favoritism
Allow for consistent auditing or adherence
Develop a consistent format

7. Format
Policy and procedure should be expressed clearly and distinctly from one another
Policy statement should be a few easy-to-understand sentences
Expanded policy can introduce purpose, background
Procedures should be broken into steps and should clearly outline expectations

8. Example procedure

9. Format Title Purpose Policy Procedure Title Policy: Procedure:
Contact:
Origination Date:
Approved by:
Signature:
Pg.# File Name
DEFINITION OF POLICY
PURPOSE(S) OF POLICY:
DEPARTMENTS AND MANUAL TO WHICH THIS POLICY APPLIES:
DEFINITION OF TERMS:
PROCEDURE(S):
APPROVED BY:
SIGNATURE:
APPROVAL HISTORY:
Page# File Name
POLICY
TITLE:
DEPARTMENT:
PUBLISHED DATE:
POLICY STATEMENT:
PURPOSE:
PROCEDURE:
OWNER
Department:
Hospital Procedure:
Responsible Unit:
Status: Draft
__________________________
Date of Procedure:
Procedure Description:.
Policy:
Process:
Approved By:_____________
Date:_____________________

10. Example Dress Code
Policy All employees are expected to wear clothing that is appropriate for their job and work site. Clothing and appearance should be neat, clean, and in good taste, and shall not constitute a safety hazard. Background XXXX interfaces with the public, and with professional vendors and organizations. As such, employees shall make reasonable efforts to project a professional public image. The following standards of dress code are established to provide direction for employees in order to maintain the professionalism that XXXX advocates.
Procedure
Employees shall practice good personal hygiene, and shall select attire that is clean and in good repair, and presents a professional image. Management may make exceptions for special occasions, and will work with Human Resources to determine whether attire is unprofessional on a case-by-case basis.
Examples of professional attire include, but are not limited to:
Business suits, blouses, shirts, skirts, pants, ties, dresses
All shirts with collars, including casual shirts and blouses, golf and polo shirts
Slacks and trousers
Sports jackets
Footwear designed for business purposes
Appropriately fitted clothing for body type

11. Supplies
Policy
For all medical and surgical supply items, [Hospital] is establishing a policy to ensure all departments follow a specific set of guidelines to determine when a supply item should be charged to the patient (chargeable) and when a supply item should not be charged to the patient (non-chargeable). The criteria that establish a medical or surgical supply as chargeable are:
The supply item should be a single use item in the provision of care to a patient, not in support of equipment or equipment maintenance
The supply item should be considered disposable
The supply item being utilized should have a “per unit cost threshold.” The per unit cost threshold is $5.00.
Procedure:
Any supply items that meet the policy criteria completely will be considered chargeable and will generate a charge to be included on the patient’s hospital bill.
The supplier coordinator/manager will update the Charge Data Master and identify all billable supplies that meet criteria
Set Billable flag to “Y”
Apply a consistent 2X markup
Exclude supplies from annual procedural markup process. EACH cost and the consistent markup will be the deciding factors on final supply charge.
Create and append bar codes to each billable supply
Perform periodic audits to validate costs
Clinical staff must scan bar codes and ensure proper billing

12. Financial Assistance Policy
 To remain viable as it fulfills its mission,  the hospital must meet its fiduciary  responsibility to appropriately bill and  collect for medical services provided to patients. 
The hospital does not discriminate on the  basis of  race, color, national origin, age,  disability, sex, gender identify, religion,  reprisal and where applicable, political  beliefs, marital status, familial or parental   status, sexual orientation or protected  genetic information in its policies or  in its  application of policies, concerning the  acquisition and verification of financial  information, pre‐admission or pre‐ treatment deposits, payment plans,  deferred or rejected admissions, Low  Income Patient status as determined by (regulation XXX)
Procedure
32 pages

13. Business Office Expectations
Payor proficiency
Account review
Clearinghouse reviews and or claim Checks (internal edits)
Who can request new edits
Timeliness of rejection review
Validation of 837, 835 files
Cash posting
Appeals
A/R or ATB
Work flow
Backlog
HIPAA

14. Coding Schedule and attendance Accuracy Production
DNFB, deficiencies and late charges
Auditing
Audit expectation of coders
Audit expectation for coders
Work at home
CEU, certification maintenance

15. Patient Access Schedule adherence Holiday, night, weekend hours
Accurate capture of data elements
Photo
Demographics
Insurance
Medicare Secondary Payor
MVA/WC
Accident info
Other
Collections
Copay, deductible, previous balances
EMTALA
Orders, authorization, medical necessity
HIPAA

16. Thank You
Stroudwater Revenue Cycle Solutions was established to help our clients navigate through uncertain times and financial stress. Increased denials, expanding regulatory guidelines and billing complexities have combined to challenge the financial footing of all providers.
Our goal is to provide resources, advice and solutions that make sense and allow you to take action.
We focus on foundational aspects which contribute to consistent gross revenue, facilitate representative net reimbursement and mitigate compliance concerns. Stroudwater Revenue Cycle Solutions helps our clients to build processes which ensure ownership and accountability within your revenue cycle while exceeding customer demands.
Contact us to see how we can help.
Laurie Daigle, CPC
John Behn, MPA