There is a lot of impact reimbursement management has on the profitability and success of the healthcare organization. In simple terms, if the reimbursement is not well managed there are negative effects on various organizational functionalities such as dropping of the revenue collection rate and an increase in billing costs. It should be put into consideration that the revenue cycle entails the gathering of the health information of the patients relevant for reimbursement. Upon the review and authentication of this information, charges are made in accordance with the stipulated costs and the services needed by the patients. It is factual that it can prove an uphill task to operate the healthcare facility without proper payment and reimbursement management.
Looking at the case of Grady memorial hospital, there is a consideration with the highest level of regard to the issue of reimbursement. The consideration and management of reimbursement are informed by the fact that it informs the crucial functionality of the healthcare organization and operations. As a matter of fact, the threat of bankruptcy is real to any business organization including the nonprofit healthcare facilities. Grady Memorial Hospital is not exceptional from such threats. Therefore, it is essential that the consideration and efficient management system is put in place to ensure the flow of operations. In case services are provided for and no payment is received in return for a better part of the cycle, there are possibilities for stalling operations. Worse is that the hospital will be exposed to bankruptcy. Again, there are possibilities for imbalance in the financial ledger which might result in financial complications.
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Important to the reimbursement cycle is the review of the data. In the event it is noted that there is a necessity for change, there will be a review of the review cycle management reports. This will be the report which entails the part of the organization taken to be giving more revenue to the organization. From such information, analysis can be conducted to establish where improvements should be done. These should follow the affirmations whether the organization was generating revenues as required.
The Revenue Cycle
The illustration above is the revenue cycle; the process begins the moment the patients are registered within the system. In the beginning, the information about the details of the patients is given and the payment is done. The insurance eligibility is verified with the aim of ensuring that the payment as per the insurance is qualified. Both the product and services are charged throughout the time the patient will be receiving the same. These charges are translated to bills through a coding system which later transforms them into invoices. For the remittance posting, there is involvement of electronic postings for the entire bills sent to the insurance company. For the denial management section, there is the processing of the claims which have been either rejected or denied by the insurance company the patient is registered in the system. Finally, a revenue cycle report is developed for the purpose of analyzing the ability of the organization to generate revenues from such claims and reimbursements.
Grady Memorial hospital provides healthcare services to its patients regardless of whether they have the insurance cover or not. Nevertheless, the patients are obliged to share the financial responsibility. At some point, the hospital was on the verge of collapsing and falling to bankruptcy. However, there are proposals for a plan in which the federal government corresponding medical is likely to give coverage to the non-covered patients (Miller, 2015). For there to be approved for the eligibility of the patients, there must be aspects of qualification of all the information needed to be backed by their personal details. It is upon the information department to ensure that the patients' information is correct and is devoid of dishonesty. Important is that the department should be considerate of the conformity of the individual details with the health records.
Departmental Impact on Reimbursement
Grady Memorial Hospital is one of the renowned healthcare facilities in Atlanta. The facility is known as one of the most formidable hospitals for the treatment of trauma in the state of Georgia. Again it’s the only level 1 trauma center within the greater area of Atlanta. The hospital has many facilities such as Brookhaven health center, East point health center, Ponce de Leone, North Fulton, and Kirkwood. On the same breath; they have specialties such as ambulatory services, asthma, and allergic clinic, dermatology clinic and burn centers.
The internal audit will be vital for the determination of reimbursement and its impact on the departments listed. This is because the internal audit is comprised of autonomous appraisal which is in custody of the information the hospital need for the operations and financial controls. Auditors in most occasions are given access to both the receivable and payable accounts. After the grant of accessibility, the auditors will compare the procedures with the organizational policies. After the completion of the auditing process, there is the preparation of reports on findings. These audits are essential for the organization in that they help the organization in knowing the points of interventions and improvements. Also, it helps in the implementation of findings made by the auditors for the betterment of the organization.
There are three measures used in the gauge for pay for performance programs and incentives. These include process measures, structural and outcome measures. Structural measures are used in to find out how the information technology facilities are utilized in the provision of clinical and healthcare services. Process measures have the responsibility to evaluate the methods used by the healthcare system to offer health services. The outcome measures are important for tracking and gauging the entire healthcare system and results.
Even though the reimbursement of resources in health facility departments vary with the size and number of patients, the mode of operations and activities are standardized. For most of the health facilities, the activities and departments begin with the front-end facility which is responsible for the capturing of the insurance data and the verification of the patients’ eligibility. Also, there is the Black-end department which is endowed with the responsibility of resolving the billing codes. Again the black end departments are given the mandate to submit the claims from the payers through the facility. The clinical department which is considered one of the most important is given the mandate to obtain the waivers and consents from patients. For the management, there are the functions of monitoring and review of performance from the entire hospital departments.
There are responsible departments for billing and coding policies. These departments are in most instances marked with exactness and rigid operations. This is because there is a need to maintain the charges at every department in the hospital. The varying charges of significance can affect the hospital billing of uninsured patients a lot of money (Hsia & Antwi, 2014). Hence the billing and coding department is given the responsibility of ensuring that the hospital is in compliance with the coding and billing policies. Further, the department is given the responsibility of actual collection of payments from the insurance companies and individual patients.
The billing and coding departments are important for the hospital in that when there are accurate billing and coding of the hospital transactions, there is the pointing out of the findings from such activities. The findings are playing a great role in the strategies which can be used for increasing the profit margins. It also creates an avenue for the training of staff for the better billing and coding whose impacts may be of importance for the overall functioning of the hospital. In addition, it promotes proper communication and coordination skills for all the hospital departments and the functioning of the management in general.
Billing and Reimbursement
Patient access personnel have a number of responsibilities and obligations to meet. First, they have to ensure that they clear all the errors before the submission of claims. Second, they have to implement all the eligibility tools confirmed to be effective. Also, they have to do necessary mechanisms to gain the confidence of the patients and to establish the responsibility of the patients in terms of financial activities. Through executing these activities and taking with much regard their responsibility, patients access personnel can help in the reduction of the accounts receivable periods outstanding. When there is open line communication for both the patient access personnel and patients, hospital staff will have a better idea on the patients’ ability to pay.
There are third party companies which provide vital medical billing services to most of the hospitals. Their involvement greatly impacts on the medical billing trust in terms of stability (Healthcare Financial Management Association, 2017). For the processing of the claims, the health care facilities depend on these third parties in accordance with the regulations and statuses. Nonetheless, there is the designing and development of compliance aimed at establishing a practice and culture within the billing company which enhances the promotion, detection, and creation of resolutions to the incidences of practices which don’t comply with the federal rules and regulations. These compliance initiatives are of importance considering the means of quality assurance and control in payment and reimbursement areas. Therefore, it is mandatory that a compliance program is initiated and form part of the billing company.
In order to ensure maximum reimbursement, it is necessary for the billing department to ensure that they collect and verify up to date information about the patient. In case of incorrect information, there are possibilities that there will be increasingly costly days of repayment. It thus means that front end office is essential for the maximization of reimbursement and creation of timeliness. Also, the billing and coding department should employ maximum keenness to ensure the elimination of errors and proper regulations are put into place prior to the submission of the claims from the patients. Through the billing specialists, there can be the calculation of the patient’s ability and potentiality to pay to arrive at the amount the patient is capable to pay hence creating visibility in the AR cycle.
In the structuring of the staff for the effectiveness, there is the need for documentation of patients’ information and the management review of the same. Monitoring and supervision of such information are key in quality assurance, control as well as improvement. There is the inclusion of documentation such as patient’s health statuses, communications attempts, and issues with medicine, post-discharge actions of the patients and the actions taken by staff to follow up on the patients’ activities. It becomes important that there is the formation of a monitoring team with representatives from all the departments including nurses, case management and information technology personnel.
Compliance plans are meant to reduce the occurrence of ethical conflicts, prevention of unverified and false claims. Through the office of inspector general, there has been seen the development of an array of educational programs as well as proper guidance tools which are used in the control of all the segments in the health care organizations and the health industry as a whole. There are stipulated steps which are fundamental for the design and development of a compliance program (Healthcare Financial Management Association, 2017). The first step entails the implementation of written policies, step two is the designation of the compliance officer, step three is the use of due diligence to delegate authority. This is followed by step four which is marked by the development of the line of communication and education of employees. After that step five comes in where there is conduction of auditing and internal monitoring. Step six is where there is enforcement of standards through the application of disciplinary guidelines. Last is the response to detected errors and responding with corrective measures.
Marketing and Reimbursement
In case there is proper management of the contract, then there can be confirmed sound financial management undertakings and strategically informed makeups. The specialist should put it as a priority to find out the role played by the payer in the signing of the contracts. During the time or if at all the organization is considering the negotiation of the relationships between the player and provider, it is good that the interest of each is arrived at. The basis which should cover the highest consideration is the timeline of the contract. The regard for the contract should be put first in that there is a need to arrive at the factors such as whether the contract is short or long term. The most fundamental interest and aim of the organization at this point should be a justified payment of services. Nevertheless, it should be considered that the fundamental objective should not form the basis for the sole interest. Thus, the organization should be considerate of the net changes rather than specifically stated rates.
When it comes to roles played by each individual in an organization as concerns the management of care contract, there is a need to include all the individual participants in such a course. All the participants and importantly the stakeholders are linked both by the contract and the financial operations. This is meant to ensure that the risk is spread among all the stakeholders and the participants. Again, there is the empowerment of both the stakeholders and participants in concern to the control of the financial stipulations put in the contract. It thus means that all the health entities such as plan sponsors, private individuals, health planning specialists, and health providers are all included in the management of the contract. It is therefore clear that the effectiveness of the management of the healthcare contracts depends entirely on the listed entities within the said contracts. Most of the directors prefer getting the analysis of their staff before nodding for the payment. This is important for analysis such as the payer responsiveness, willingness, and desire for the solution to problems which might arise. The staff, in this case, might include the billing team, insurance management, and denial management staff members.
Managed healthcare contracts pose impacts in the general reimbursement of the healthcare system and particularly the healthcare organizations. First, it should be understood that a managed health contract represents a better portion of the revenue generated in the entire healthcare system. Important to consider is that the health programs and plans actualized and paid through capitation have many incentives geared at distorting the quality of services rendered (Frank, Glazer & McGuire, 2017). This is meant to attract profits and generally to prevent any eventuality like unprofitable personnel and registrations. An effectively negotiated contract is good in the creation of an environment for additional revenue through initiatives like insurance models and products. Also, a managed contract is capable of the satisfaction of patients in that there will be faster access to treatment and other healthcare services.
References
Frank, R. G., Glazer, J., & McGuire, T. G. (2017). Measuring adverse selection in managed health care. In Models of Health Plan Payment and Quality Reporting (pp. 29-57).
Healthcare Financial Management Association. (2017). Successfully Negotiating Managed Care Contracts. Retrieved December 03, 2017, from http://www.hfma.org/Content.aspx?id=16658
Hsia, R. Y., & Antwi, Y. A. (2014). Variation in charges for emergency department visits across California. Annals of emergency medicine , 64 (2), 120-126.
Milner A. (2015). Grady outline plan to transform care for the uninsured. Georgia health news . Retrieved from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=12&cad=rja&uact=8&ved=2ahUKEwjsx-
