How effective a healthcare organization manages the reimbursement process influences the overall organization's profitability. According to Merrit (2019), the mismanagement of reimbursements in the various organizational departments tends to increase the billing costs, cause a decrease in the revenue collection rates leading to a general increase in the receivable accounts. Generally, mismanagement of reimbursements in a healthcare organization hinders the attainability of the acquisition value. According to Rauscher (2010), the US health system is characterized by complex relationships among the healthcare providers, patients, regulators, and payers, which influence the way healthcare institutions, manage the patient’s revenues. The management of a revenue cycle in a hospital involves all the administrative and clinical activities that are focused on generating, managing, and collecting the patient's care costs (Rauscher, 2010). For example, a patient involved in a car accident coming through the emergency department is triaged and assessed in the area as his relatives are involved with the access department to validate the insurance status.
The revenue management sector collaborates with revenue-producing centers such as lab works to ensure they have all the necessary charges for proper billing of the services provided (Rauscher, 2010). In cases of more lab tests the clinical team responsible contact the revenue department that researches and charges for the added services. According to Rauscher (2010), denial and rejection management steps in if the claim does not go through after the patient is discharged to assess the underlying issue to the problem. The revenue management ensures all the charges are captured through searching for the diversified cost centers to ensure thy own up their processes. According to Britton (2015), the revenue management works in collaboration with other centers to discover new opportunities to help increase revenue. The revenue management uses the available reimbursement data to get more information on the charges getting lost to help minimize them. The department works on various reimbursements mechanisms to determine their weaknesses and strengths hence, agree on the ones to adopt. Britton (2015), explains that the pay for money incentives mostly correlate quality to payment, which involves the process of comparing set outcomes to past performance or the successful performance of other health providers.
Delegate your assignment to our experts and they will do the rest.
Every department in the revenue cycle plays an important role in reimbursement in the healthcare organization. According to Rauscher (2010), the access department emphasizes all the front-end processes such as scheduling the patient, securing hospital payments through the insurance verification process, and authorization of the account. The access employees also scrutinize the Advance Beneficiary Notice to assess whether the diagnosis provided meets the Medicare standards (Rauscher, 2010). The revenue management body is concerned with the charge description master and charge capture processes (Rauscher, 2010). To meet the requirements for charge descriptions, the revenue management provides charge codes for every item together with revenue code (Rauscher, 2010). Adherence to Medicare's accurate coding requirements is necessary for revenue management as any inaccurate procedures and descriptions can cause a rejection of the bills (Rauscher, 2010). Therefore, frequent audits on the chargemaster are necessary to maintain a match on the descriptions of various procedures, which can result in billing problems. The denial management steps in when the insurance companies reject the claims (Rauscher, 2010). If the insurance claim is rejected for certain reasons such as billing late and unnecessary medical procedures the rejection department works with the clinics involved with the processes to research the problem. The rejection and denial department then approaches the insurance company with the reasons necessary to help claim the revenue.
The hospital billing departments face various problems as they try to understand and comply with the billing requirements of Medicare. According to Merrit (2019), the billing personnel can affect the reimbursement process in Medicare through cost-cutting, compliance, and external audits. Therefore, the application of accurate and timely coding in billing that facilitates the generation of Ambulatory Payment Classification (APC) sets is necessary to fasten the billing process. Departmental emphasis on the audit checks regularly ensures a complete and accurate coding scheme is in use (Merrit, 2019). More so, the regular checks maintain successful APC reimbursements within the organization. A timely follow-up audit in every department can help the billing department in identifying, reviewing, and correcting any malpractices, which affects the institution’s profits while complying with the Medicaid requirements of the US government (Merrit, 2019). Nevertheless, the follow-up audits also facilitate procedures necessary in the billing and coding issues to improve accuracy and quality in their operations.
References
Britton, J. R. (2015). Healthcare reimbursement and quality improvement: Integration using the electronic medical record: Comment on" fee-for-service payment-an evil practice that must be stamped out?". International journal of health policy and management , 4 (8), 549. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529047/
Merritt, S. (2019). Successful Billing Strategies in the Hospital Industry. (Doctoral dissertation) https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=7900&context=dissertations
Rauscher, S. (2010). Revenue Cycle Management in the US Hospital Industry (Doctoral dissertation). https://deepblue.lib.umich.edu/bitstream/handle/2027.42/77931/srausche_1.pdf?sequence=1
