Question 1
Healthcare reimbursement is a complex system aimed at obtaining payment for the services offered to consumers. One of the key challenges facing reimbursement in the institution is the changing rules. The insurance payers have different healthcare reimbursement plans and formulate contracts with health systems and individual practices. It means that there may be one price for services in a certain healthcare system that has been agreed with a particular payer and a different price for other services that may occur outside that particular system ( Wright, 2017) . Money paid out of the pockets, and the reimbursement on the claims filed is the basis of the institution's revenue cycle. The ability to collect payments and efficiency of managing the payment processes is an indication of the system's financial health. Executing the revenue cycle management may be challenging because of ensuring payments are made at the right time and getting maximum payments for the services provided to their patients.
If the codes and procedures given in the insurer's provider's transaction are matching with the data sent by the healthcare provider, then all the medical charges are compliant with the monetary agreement between the two parties. Also, the healthcare provider will receive the required reimbursements for the medical services offered to the patients, and the payments are implemented on the patient's account. However, in situations where the insurance provider has not covered some of the services offered, and some portions of the bill are unpaid, the leftover charges are passed on to their patient ( Mindel & Mathiassen, 2015) . Furthermore, the medical biller should confirm whether the total billed to the patient, in addition to the reimbursed amount by the insurance providers equals the predicted cost for all the medical services offered by the institution. On the other hand, they should ensure that the bill includes all information about transactions if the bill will be paid directly by the patient.
Delegate your assignment to our experts and they will do the rest.
Question 2
The schedules must be updated regularly for rescheduled appointments, cancellations, and no-shows. The daily schedules can be used to reconcile most of the daily charges. Pre-registration occurs before the patient visits the hospital. During registration, the following processes should occur: acquiring the needed pre-authorizations, verifying insurance coverage, identifying self-pay balances, and verifying patient demographic information ( Post, 2016) . The acquired information should be recorded. Registration involves acquiring copies of the insurance cards, practicing the birthday rule, acquiring a photo ID from the patient for verification, verifying their demographic information and documenting it in the system, and collecting the monies required from the patient. All the information should be accurately recorded in the system for current and future retrieval.
In the charge capture, the physician assistant, physician, or nurse documents all the services that will be rendered to the patient. The charges that are captured in their systems via clinical departments are forwarded for entry into the Hospital Information System (HIS). Some CPT (Current Procedural Terminology) codes are then hard-coded into their CDM (Charge Description Master) according to the charge. The medical records in the HIS determine the coding. After they are captured, the information/codes are moved or transferred from the coding system to the medical records/HIS through various means such as interfacing ( Wright, 2017) . Contractual Service Adjustment (CSA) involves correcting the errors that were identified, calculating the CSA and posting it to the patient’s account. It is based on their method of payment. The claims become ready for submission for the different insurance carriers who mainly require electronic claim submission. The follow-up process involves paying off the outstanding claims. Most hospitals have productivity tracking to monitor their follow up efficiency.
Question 3
The departments according to their level of importance in the cycle are:
Patient Access
Hospital
Documentation of Services
Billing
Receivable Management
Customer Service
Patient access is the main access and the first step in its revenue cycle process. It is responsible for about 50% of claims data, scheduling services, Medicaid legibility, verifying insurance, financial counseling, obtaining certifications and authorizations, identifying physician, and giving referral information. There are critical activities that take place in the hospital such as patient discharge, care delivery, discharge planning, case management, and utilization management. The patients meet the physicians and are later discharged according to their condition ( Mindel & Mathiassen, 2015) . The documentation of services takes care of issues such as late charges, chargemaster, charge capture, transcription, and coding. The department acts as the liaison between all the areas in the hospital and is responsible for the storage and retrieval of all medical records. It is where the Health Information System is located.
The billing department is responsible for the patient statement, claims editing, contractual adjustments, bill reconciliation, and claims submission. It is one of the key processes in the revenue cycle because it touches all departments. It ensures that all billable charges appear in the CDM. It considers the market pricing and transparency. It is responsible for the accuracy of charges. Receivable Management takes care of legal collections, payment posting, write-offs/bad debts, secondary billing, denial/appeals management, and follow-ups ( Post, 2016) . Follow up with the insurance providers is vital in the revenue cycle for reimbursement. If the insurer has not covered some section, the leftover payments are paid by the patient. The customer service includes issue resolution and customer inquiries. Patients should raise issues if the standards of care in the hospital have been inadequate or any other problem that arose during or after treatment or consultation.
References
Post, W. W. (2016). Health Care Reimbursement-A Short History.
Mindel, V., & Mathiassen, L. (2015). Contextualist Inquiry into IT-enabled Hospital Revenue Cycle Management: Bridging Research and Practice. Journal of the Association for Information Systems , 16 (12), 1016.
Wright, K. (2017). Revenue Cycle and Reimbursement. Health Information Management: Principles and Organization for Health Information Services .
