The medical coding process is an involving activity undertaken by different parties within a healthcare organization. Coding is the process which medical coders allocate digit codes to a patient’s medical diagnosis in order to bill the respective payer for reimbursement to healthcare providers. The process utilizes the services of receptionists and other administrators in the “front-of-house” as well as medical coders in the “back-of-house.” Medical coders act as a bridge between patients, healthcare providers, and insurance companies. The process of coding in healthcare requires critical analysis of patients’ history to develop “shorthand” used by healthcare organizations and the insurance companies. Besides, there are differences between pricing and charging in healthcare and other industries. The government and private insurers and payers also impact on actual reimbursement in healthcare.
Sufficient education in medical terminologies forms the basis of the responsibilities of medical coders. Knowledge ensures that the process of coding is carried out smoothly within a short time. The process of coding begins with medical coders verifying the doctors claim to ensure that everything is billed and coded. In some healthcare organization, the coders are responsible for translating patients chart into medical codes. The coder ensures accuracy is maintained and also countercheck if the process coded is billable depending on the patient’s diagnosis, procedures, insurance plan and regulations set by the payer (Savarise & Senkowski, 2016). For medical coding, the coders utilize three major coding manuals which carry all the medical codes needed to be included in a patient’s claim for reimbursement. Current Procedural Terminology (CPT) codes shows the procedures taken to examine a patient medical problem by physicians, Health Common Procedure Coding System (HCPCS) codes represents other minor services provided to the patient by healthcare providers and International Classification of Disease (ICD) codes which explains to the insurance company why the patient sought for medical care (Savarise & Senkowski, 2016). The three sets of codes are combined by the medical coders and set on the insurance claim for reimbursement.
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Differences in pricing and charging between the healthcare industry and other industries
Healthcare industry charging and pricing varies greatly from other industries. Here, care providers charge for both services they provide in offices and surgery. Healthcare charging and pricing keep up with insurance billing guidelines daily. Compliance to charging policies in healthcare is mandatory, unlike other industries. Like other industries, technology has greatly impacted on the healthcare industry. Other industries have resulted in developing an automated uniform pricing process for their services. Healthcare industry, however, utilizes an anti-automated process since the pricing here depends on the patient’s diagnosis and the procedures used by physicians. It also requires a process that follows a patient by patient means, thus cannot be fully automated. Besides, in the healthcare industry, the charges keep on fluctuating rather than increasing with the growth in the industry. This is different from other industries where the forces of demand and supply impacts on the prices of goods and services or industries where prices increase during high season (Miller, 2009). The medical sector is least affected by demand and supply forces. The price change is triggered by the government and private insurers’ policies. The industry also does not experience recession or upswing because other players such as Medicare in the US control the pricing in healthcare. Additionally, many other service provider industries tailor their services and set prices depending on the target customers (Miller, 2009). Nonetheless, the medical industry has no target customers. It serves every customer who seeks and affords to pay for the services provided. For instance, the emergency department has the responsibility to provide care to all patients taken, while the cost is determined based on the set regulations.
Impacts of private and government insurers and payers on reimbursement
Private and public insurers and payers are vital players in the actual reimbursement in the healthcare industry. In this industry, customers pay for the services in advance to the service provider indirectly. Healthcare organizations, in turn, receive reimbursement of the care provided to the patient from the private or government insurers. The insurance agencies, both public and private, determine the amount to be reimbursed on a patient or a healthcare organization based on the policy agreement and care provided. For the healthcare organizations to receive reimbursement from the payers, all the basic policies set by the payer must be adhered to. These include the correct coding and billing process. Both government and private payers critically follow the guidelines provided by Medicare before the actual reimbursement (Antoniotti, Drude& Rowe, 2014). In the US, however, there is a massive competition between both public and private insurers and payers. As a result of the Affordable Care Act (ACA), more than two-thirds of Americans have turned to private insurers for convenience. Although various private payers have different policies in their business, they are tied in specific ways to Medicare. Still, individual private and government payer policies impact on the actual amount reimbursed to physicians. For example, both private and government insurers and payers may reimburse a lower amount than the cost coded by care providers if an aspect of the policy is not adhered to during the coding process. Also, insurance policies have certain deductibles. Thus the insured bears the cost of the deductible before reimbursement. Additionally, the payer policy is built on trust. If altered information is intentionally or otherwise coded and submitted to the payer, physicians may not receive reimbursement (Antoniotti, Drude& Rowe, 2014). Similarly, some insurers impose caps on particular care, such as a cap on intensive care unit costs. In such a case, the payer only reimburses the target amount on the policy document while the patient caters for the rest amount.
The process for producing a final bill in healthcare involves various parties such as physicians and coders. For reimbursement to be made, systematic and clear procedures must be followed and all necessary information included during the coding process. Healthcare industry operates exclusively different from other industries in different aspects. Pricing and charging are specifically unique in healthcare industry compared to other service provider industries. For example, strict regulations, universal services, and constant prices are involved in the medical industry. On the other hand, the individual and public insurers and payers determine the amount of compensation and eligibility of patients and healthcare organization for reimbursement based on the policy and services provided. Both government and private payers are tied to the policy of reimbursement set by Medicare for reimbursing healthcare physicians.
References
Antoniotti, N. M., Drude, K. P., & Rowe, N. (2014). Private payer telehealth reimbursement in the United States. Telemedicine and e-Health, 20(6), 539-543.
Miller, H. D. (2009). From volume to value: better ways to pay for health care. Health Affairs, 28(5), 1418-1428.
Savarise, M., & Senkowski, C. (Eds.). (2016). Principles of coding and reimbursement for surgeons. Springer.
