3-2 Final Project Milestone One copy
docx
keyboard_arrow_up
School
Southern New Hampshire University *
*We aren’t endorsed by this school
Course
345
Subject
Health Science
Date
Feb 20, 2024
Type
docx
Pages
6
Uploaded by UltraAtomNightingale32
1
3-2 Final Project Milestone One: Draft of Departmental Impact on Reimbursement
Business Administration, Southern New Hampshire University
HCM 345: Healthcare Reimbursement
Professor Candice Faison
November 12, 2023
2
“
Healthcare reimbursement describes the payment that your hospital, healthcare provider,
diagnostic facility, or other healthcare providers receive for giving you a medical service.” (Torrey, 2020). The payments for the services provided are dependent on the patient. Some patients will have government payers such as Medicare, Medicaid, and Tricare and some patients
may have private health insurance through their employer like Blue Cross and Blue Shield, Cigna, and Harvard Pilgrim. Both government payers and private payers may have coverage where the charges are not paid in full, and a balance is due from the patient. If a patient does not have any insurance coverage, then they would be considered self-pay and the facilities reimbursement would come solely from the patient.
Healthcare reimbursement is different from other industries, and it is much more convoluted. When we go into the grocery store there are prices on everything, and it is easy for us to know how much we are going to pay and that is not the case in healthcare. In healthcare when a person presents for treatment there is no way to know what services they will need, how much it will all cost and how much the patient will be responsible for. Healthcare Reimbursement is a very complicated process.
If a facility provides medical services and fails to receive reimbursement for those services, it will affect the facilities financials. Facilities provide services with the expectation that they will be reimbursed either from a government payer, private payer, or the patient. “
Healthcare revenue cycle management
begins when a patient makes an appointment to seek medical services. The process ends when organizations have collected all claims and patient payments.” (Lapointe, 2018). The revenue cycle
3
management is divided into three categories which is front-end process, middle process, and the back-end process. The front-end process includes pre-
registration, registration, prior authorizations, and insurance verifications. During
this process all demographic information including insurance information is obtained. Insurance co-pays should also be collected during this stage. The middle-process is where case management can get involved as well as charge capture, hard coding and soft coding of diagnoses and procedures. This is when HIM/Coding will apply the ICD-10 diagnosis codes and correct CPT codes based on
documentation. The back-end process lands with patient financial services and this includes processing bills, posting payments, handling denials and any credits. Denials can include incorrect diagnosis codes; medical necessity related to payer policies/regulations and charge errors. All stages of the revenue cycle are vital to reimbursement, but pre-
registration and registration are key as it is the first step to make sure the facility/provider has all the correct information for the patient. If information is not accurately obtained at the beginning, then the rest of the revenue cycle process will be difficult and can cause potential issues and denials. There are many different departments that utilize reimbursement data starting with all revenue producing clinical departments such as radiology, oncology, rehab, and physician practices. These departments all utilize the data, so they know if they are receiving reimbursement for the services they are providing. All areas of revenue cycle utilize reimbursement data to ensure the facility is getting reimbursed for the services they are providing
and if they are not, they investigate what could be causing the issue. Are there any trends that are related to any issues in any of the revenue cycle stages. Administration also utilizes the data,
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
4
so they understand if there are any changes need regarding processes or prices. They would also use the data for budgeting purposes. Collecting data is very important when it comes to pay-for-performance incentives because if the data needed is not available then the facility could be losing incentive reimbursement that they are entitled to. “
Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. These arrangements provide financial incentives to hospitals, physicians, and other health care providers to carry out such improvements and achieve optimal outcomes for patients.” (James, 2012). While reimbursement is very important and healthcare facilities should always seek any incentive they can, quality patient care is even more of a top priority. Pay for performance has become popular recently with government and private payers and this includes Medicare and Medicaid. This is because for many years reimbursement was paid based on volume and not quality of care and if it is not transitioned to pay-for-performance reimbursements it can be harmful to patients when they don’t receive quality care. The department responsible for ensuring compliance with billing and coding would be all
the revenue cycle departments (Registration, HIM/Coding, and Patient Financial Services) but primarily HIM and Patient Financial Services. There are many regulations that each of these departments need to follow to ensure compliance. Regarding the departments impact on reimbursement for the organization it will reflect in a positive way if we are following policies and procedures because this should prevent denials and potential issues. Audits on accounts for each departments work will help to ensure compliance.
5
References
:
Harrington, M. K. (2019).
Health care finance and the mechanics of insurance and reimbursement
(2nd ed.). Jones & Bartlett Learning. LaPointe, J. (2018, December 17).
What Is Healthcare Revenue Cycle Management?
RevCycleIntelligence. https://revcycleintelligence.com/features/what-is-
healthcare-revenue-cycle-management
Torrey, T. (2020, February 27).
How Healthcare Providers Are Paid by Reimbursement
. Verywell Health.
https://www.verywellhealth.com/reimbursement-2615205
James, J. (2012). Pay-for-Performance.
Health Affairs
.
https://doi.org/10.1377/hpb20121011.90233
6
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help