reimbursement is not handled correctly in most departments billing costs will
increase and collection rates will on the other hand drop resulting in an
increase in accounts receivable: this makes value of the acquisition a lot
harder to attain. Appropriate management in all departments helps the
organization to attain a site-level control as well as establish a close
relationship between every patient and physician.
reimbursement billing mostly depends on timely and accurate use of HCPCS/CPT
codes, which generate Ambulatory Payment Classification (APC) groups. The regular audit checks the department to
ensure that an accurate and complete coding system is in point, which it quickly
ensures success in APC reimbursement for the facility. Also, a constant
follow-up audit on the other hand guarantees that the organization identifies,
reviews and resolves unsuitable practices and this also impact on the
facilities profits. It emphasizes prospective concerns with compliance.
Follow-up audits also ensure procedures are in place to tackle issues on
quality and accuracy of coding and billing processes (Abbey, 2008).
to Herbert (2012), there are three measures to gauge pay-for-performance
incentives; they are structural measures, outcome measures and process
measures. Most structural measures need for a facility to collect data and account
how the facility’s IT systems are used in helping out in the clinical care.
Structural measures are organizational and professional resources related with
provision of care including running capacity and staff credentials. These measurements
determine the care attributes such as material resources, human resources and
the organization’s structure.
measures evaluate the methods by which care is provided. This measurement
reflects procedural tests, surgeries as well as other actions in the course of
treatment. The measures focus on the ability of the facility to detect,
diagnose as well as manage the disease. In addition, they capture the
timeliness as well as accuracy of various diagnoses, appropriateness of therapy
and complications that took place during treatment if any. All of these
measures are routinely reported to the CMS, private payers as well as
third-party groups to help them prepare report cards. Patients use these
reports to compare quality of facilities, physicians and health plans and the
final measures are referred to as the outcome measures. These measures are used
to track the desired state that result from care processes and they also
highlight the effect of process or structure measure types on each patient. Basically,
outcome measures gauge the result of the whole care process; Structure and
process measures lead up to outcome measures. Outcome measures are also used to
track satisfaction of patients with their care (Harrington, 2016).
to Casto & Layman (2006), successful reimbursement claims go through a
processing operation comprised of skilled personnel as well monitored
processes. Even though departments involved in reimbursement may vary from one
facility to the other, activities involved in the reimbursement process are typical.
The breaking down of actions across departments is as follows: The front-end
department captures insurance data and verifies eligibility of the patient. Staff
in this department also obtains referrals, conduct initial authorization as
well as collect co-pays and deductibles during the time service is being
offered. The Back-end department on the other hand tracks and resolves billing
edits, conducts timely submission of the facility’s claims to payers and
follows up on outstanding accounts. In addition, the department posts denials
and engages in accurate payment recording. The clinical department is only
involved in obtaining patient consents and waivers. The management on the other
hand ensures communication and timely feedback for all stakeholders involved in
the reimbursement process. Management also monitors performance, reviews
revenue cycle metrics, and analyzes trends regarding reimbursement.
(2008) argues that the billing and coding department is in control of ensuring
that a hospital complies with medical billing and coding policies. This
department includes front office administrators and back office staff such as
the medical billers and coders. The main responsibilities of these departments
are to comprehend the patient’s responsibility for payment, which it differs
from one patient to the other. It also has the duty of analyzing medical
charges, insurance coverage and preparing accurate billing forms. In addition,
the department also has the responsibility with the collection of payments from
patients and insurance companies.
complete-accurate management of the coding/billing process and actively reviewing
the revenue cycle helps the organization to identify opportunities for enhancement
and cost reduction. Which in return it also helps to increase the
organization’s profit margins big time and it then results in a coordinated, ascendable,
and strong practice-management system. Also, it promotes training of staff in
the departments to ensure proper skilled payment billing. In addition, it
promotes accountability and coordination between the front-end department and
the back-end department. This also promotes consistent, correctly documented as
well as properly linked performance expectations and procedures. Adherence to
the policies promotes effective management and reporting based on relevant
performance metrics (Harrington, 2016).
Abbey, D. C. (2008). Compliance
for Coding, Billing & Reimbursement: A Systematic Approach to Developing a
Comprehensive Program. CRC Press.
Casto, A. B., &
Layman, E. (2006). Principles of healthcare reimbursement. Chicago:
American Health Information Management Association.
Harrington, M. K. (2016).
Health Care Finance and the Mechanics of Insurance and Reimbursement.
Jones & Bartlett Publishers.
Herbert, K. (2012). Hospital
Reimbursement: Concepts and Principles. CRC Press.