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Reimbursement and the Revenue Cycle

What is Reimbursement

Healthcare providers are reimbursed for their services by customers, insurance firms, and government agencies. This money is used to maintain the building and keep it open for business. The phrase “the payment that your hospital, healthcare provider, diagnostic facility, or other healthcare providers receive for giving you medical service” describes healthcare compensation perfectly (Torrey, 2020).

Patient Flow through the Revenue Cycle

Everything that happens between a patient’s registration and the time that money is collected from their provider (typically an insurance company or the government) is part of the revenue cycle. (e.g., Medicaid). funds for patient services (reimbursement) are essential to the daily operations of healthcare providers, so delays in receiving these funds can have a significant impact on business as usual. Money is needed to buy materials, pay employees, and resolve debts; without it, the company will be unable to function normally. Preregistration is the first stage, and it involves the hospital acquiring patient data, insurance details, and criteria verification in real time via a clearing house, typically at the time of appointment scheduling. Through the provider’s EHR, the patient’s insurance company receives the collected data, which informs the provider about the patient’s financial responsibility, if any, the expected date of payment, and the provider’s no-show/cancellation policy. The next phase, patient registration, involves verifying the veracity of the patient’s pre-registration data, collecting any necessary co-payments, and getting the patient to complete any necessary paperwork. (financial).

The next step, charge capture, is to translate the expense of the treatment or service provided into an invoiceable amount. Automatic charge capture occurs when “information automatically flows into the practice management billing side based on what the provider puts in their documentation” (Carney, 2022). Manual charge capture occurs when the front desk employees or claims department completes the process. At this point, if services are not recorded properly, payments may be missed and applications may be rejected. Claims are submitted to the clearance house and then on to the creditor after all costs have been recorded and double-checked for accuracy (claim cleaning). Remittance handling follows, wherein the supplier is reimbursed in response to the claims that have been made. The insurance company confirms the amount they are willing to pay for a service and the supplier is free to charge whatever was agreed upon in the contract for the service. The accounts outstanding account is the result of the insurance follow-up procedure, which includes checking what has been paid, what has not been paid, negotiating if necessary, and resubmitting. A breakdown of any costs not paid by the patient’s insurance or other provider. After insurance and other payments have been made, what’s left over is the patient’s obligation; if the account isn’t settled within a reporting period, it goes to collectors.

Departmental Impact on Reimbursement

Marketing and Reimbursement

Relevance of Data Collection for Pay-for Performance incentives and Data Monitoring.

Claims filling and other administrative tasks are often based on information gathered during the patient enrollment process, which is why it is crucial that this information is accurate. The billing office (claims department) is in charge of ascribing the appropriate reimbursement code to the services and procedures rendered to patients, submitting the necessary paperwork to healthcare payers for reimbursement, keeping track of claims, collecting payments, and following up with healthcare payers in the event of a claim being delayed, denied, or otherwise not resolved. (AdvancedMD, 2020). The organization loses money if it doesn’t keep an eye on refund data and corrects any mistakes it finds, particularly in labeling, which can cause claims to be rejected or go underpaid. Improper management of the payment process can have a negative impact on a business’s bottom line, security (discipline), and connection with its customers. (Harrington, 2016). The structural measure (how the IT systems support patients’ care), the process measure (how the care is actually delivered to the patient), and the outcome measure (how the patient is doing after receiving treatment) are the three types of evaluations that make up the pay-for-performance (value-based purchasing) incentive.

Activities that Impact Reimbursement

While the specific roles played by various divisions in the reimbursement process will vary from one organization to the next, the reimbursement process as a whole will follow and stick to the same rules and laws regardless of the entity being reimbursed. At the front counter, paperwork is filled out and information is collected to begin the reimbursement process. This includes collecting patient data, insurance information to determine status and accountability, co-pays and premiums, and reference information if necessary. Because front-desk data collection sets the tone for all other divisions in giving the proper numbers, errors there can lead to higher out-of-pocket costs for patients or reduced income for the healthcare company. Clinical staff continue the process by providing care to patients and recording their care, before sending the information to accounting to submit a claim using accurate coding that corresponds with the services provided. The invoicing section is responsible for sending claims to the healthcare provider via the clearing house, keeping tabs on payments, following up on claims that have been paid late or rejected, and charging patients for any remaining balances. If the accounting staff makes a mistake in designating codes, the hospital could lose money or the patient’s co-pay would go up. Through prompt and clear communication, close tracking of employee performance, and critical analysis of the revenue cycle and new patterns in the repayment process, management guarantees the process runs smoothly (Harrington, 2016).

Department Responsible for ensuring Compliance with Billing and Coding Policies.

Compliance with healthcare invoicing and labeling regulations is the responsibility of the health information management (claims) division. In order to ensure that the facility is running smoothly and profitably, they perform tasks such as reviewing patients’ treatments and procedures to determine what is covered and assigning the correct code to treatments and services, determining patients’ responsibility, processing the claim, and sending it to the healthcare payer, tracking payment and following up on unpaid or denied claims, and reviewing and monitoring the revenue cycle to ensure accuracy and compliance with regulations and policies.

Billing and Reimbursement

Patient Financial Services (PFS) Personnel and how Third-Party Policies impact the Payer Mix for Maximum Reimbursement?

Employees in Patient Financial Services (PFS) play a crucial role between patients and payers by handling billing and collection activities like checking that correct codes are used, keeping tabs on the reimbursement process, and analyzing the data to determine where adjustments can be made to increase the facility’s ability to collect. The PFS staff needs to be properly educated and equipped with the tools they need to do their jobs effectively and efficiently. Payer mix refers to “the proportion of patients covered by commercial or ‘private’ insurance versus public health insurance programs like Medicare and Medicaid.” (Frenz, 2020). Healthcare institutions depend on the difference between what commercial/private insurance pays and what the government pays for medical services. Compliance with revenue cycle policies and standards is essential for maximizing compensation because it increases the likelihood that claims will be paid and decreases the likelihood that they will be denied or delayed.

Key Areas of Review in order of importance for Timeliness and Maximization of Reimbursement from Third-Party Payers

Checking that all patient data collected during the pre-registration and registration phase, including demographics, insurance information, deductibles, co-pays, and patient responsibility, is accurate is the first step in ensuring timely and maximum reimbursement from third-party payers. Accurate documentation of all patient therapies and processes is essential because it sets the tone for claims handling. This is because incorrect information can lead to the application of incorrect codes during the claims processing phase, which in turn can cause a delay in payment or even a rejection of the claim. The next step involves using qualifying tools to confirm the details of patients’ pre-register, registration, diagnosis, therapy, and medical follow-up care. Claims will be processed more quickly and accurately if the correct numbers are used for all services rendered to the patient. Claims processing is the next step, and it entails verifying that each service rendered to a patient has been appropriately coded, submitting those claims to third-party payers via a clearinghouse, and then following up with those payers if payment is delayed, denied, or otherwise unexpected.

Plan for Periodic Review of Procedures to ensure Compliance.

Compliance with standards, laws, policies, and regulations, as well as the identification of compliance risks and mistakes, rely heavily on routine reviews of processes. If you want your compliance plan to be effective, you’ll need to put in place some written procedures, an ethical code of conduct, and some guidelines, as well as a compliance officer and advisory committee to keep an eye on things and make sure nothing gets in the way of timely reimbursement. It’s crucial to hold regular training sessions to inform the team of any new policies or enhanced methods. In order to prevent any misunderstandings that could lead to mistakes, it’s important to establish clear channels of communication. Make sure everyone is on the same page by having an internal audit/monitoring and peer evaluations performed. The results of an external audit or examination can help fill in the gaps that may have been overlooked during an internal audit. Finally, guarantee rapid reaction to identified issues and take remedial action by disciplining or reprimanding employees who don’t play by the rules.

Marketing and Reimbursement

Managed Care

The goal of the managed care system is to keep healthcare expenses down without sacrificing quality. This is accomplished by a managed care company and its affiliated healthcare providers/physicians through the delivery of uniform treatment across the complete managed care network and the integration of payment with health results, quality, and usage. (PayrHealth, 2021). Healthcare cost containment is a primary concern for managed care organizations like Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) Organizations, and Exclusive Provider Organizations (EPOs), as stated by Harrington. (Harrington, 2016).

Impact of New Managed Care Contracts on Reimbursement.

Reimbursement is linked to health outcomes and the quality of care provided to its beneficiaries, which can be affected by managed care contracts because they involve a healthcare provider negotiating a contract with a manage care organization, such as an HMO, to determine what care the healthcare provider should give and at what cost. Providing treatment to a recipient outside of the managed care contract may result in a claim rejection because of the contract’s influence on the provider’s payment. Since beneficiaries are required to use only “in network” providers, it is the provider’s responsibility to ensure beneficiaries receive outstanding care (customer service/satisfaction) that will lead them to remain satisfied enough with the provider to continue using that healthcare provider. Failure to comply with established practices, protocols, and rules can cause delays in payment, which is another area in which MCO can have an impact.

Resources needed to ensure compliance with Billing and Coding Regulations

Billing and coding conformance with laws and ethical standards requires the following resources: having documented standards and instructions that are accessible to everyone to prevent misinformation and also to keep everyone in line, Having regular meetings with compliance committee members to evaluate findings and discuss corrective action, establishing and maintaining clear lines of communication to ensure that everyone is kept up-to-date in a timely manner (this also means being open to constructive criticism), providing facility staff with regular opportunities for training and education to ensure that they are up-to-date on the latest technologies, models, and policies, conducting audits and monitoring to identify deviations from the set guidelines and adherence to rules, and enforcing these measures are all essential. Failure to adhere to ethical standards can result in fines, the suspension or revocation of licenses, the firing of employees, and the loss of jobs; delays or denials of claims; dissatisfied consumers; the loss of business; and the loss of business and employment.

Strategies to ensure Stakeholders Adherence to Ethical Standards in the Reimbursement Process

Strategies to ensure stakeholders in the reimbursement process adhere to ethical standards include providing them with written sets of standards and policies, maintaining an effective communication line, conducting audit and monitoring to ensure compliance, training and educating stakeholders, and enforcing the adherence to guidelines through corrective measure.


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