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 operational measures do require 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 delivery of care including running capacity and staff
credentials. All of the 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 relevance
as well as accuracy of various diagnoses, suitability of therapy and
complications that took place during treatment if any. All of these measures
are normally 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 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 remaining accounts. In addition, the department posts denials
and makes sure there is an accurate payment logging. The clinical department is
only involved getting 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 overseers 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 many insurance companies.
complete and 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.