Harringtonargues that management of the reimbursement process affects profitability of anorganization. If reimbursement is not managed effectively in these departments,billing costs will increase, collection rates will on the other hand drop resultingin an increase in accounts receivable.
This makes value of the acquisitionuntenable. Proper management in the department helps the organization to attaina site-level control as well as establish a close relationship between patientsand the physicians.Thereimbursement billing depends on timely and accurate use of HCPCS/CPT codes,which generate Ambulatory Payment Classification (APC) groups. Regular auditchecks the department to ensure an accurate and complete coding system is inplace. This ensures success in APC reimbursement for the facility.
A periodicfollow-up audit on the other hand ensures the organization identifies, reviewsand rectifies inappropriate practices which impact on the facilities profits.It highlights potential issues with compliance. Follow-up audits also ensureprocedures are in place to tackle issues on quality and accuracy of coding andbilling processes (Abbey, 2008).Accordingto Herbert, there are three measures to gauge pay-for-performance incentives; theyare structural measures, outcome measures and process measures. Structuralmeasures require a facility to capture and report how the facility’s IT systemsare used in aiding clinical care. Structural measures are organizational andprofessional resources related with provision of care including operatingcapacity and staff credentials. These measures gauge care attributes such asmaterial resources, human resources and the organization’s structure.
Process measures evaluate themethods by which care is provided. This measurement reflects procedural tests,surgeries as well as other actions in the course of treatment. The measuresfocus on the ability of the facility to detect, diagnose as well as manage thedisease. In addition, they capture the timeliness as well as accuracy ofvarious diagnoses, appropriateness of therapy and complications that took placeduring treatment if any. 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 andhealth plans.
The final measures are referred to as the outcome measures. Thesemeasures are used to track the desired state that result from care processes.The measures also highlight the effect of process and structure measure typeson patients. In essence, outcome measures gauge the result of the whole careprocess. In this regard, structure and process measures lead up to outcomemeasures. Outcome measures are also used to track satisfaction of patients withtheir care (Harrington, 2015).Accordingto Casto & Layman (2006), successful reimbursement claims go through aprocessing operation comprised of skilled personnel as well monitoredprocesses. Although departments involved in reimbursement may vary from onefacility to the other, activities involved in the reimbursement process arestandard.
The breaking down of activities across departments is as follows: Thefront-end department captures insurance data and verifies eligibility of thepatient. Staff in this department also obtains referrals, conduct initialauthorization as well as collect co-pays and deductibles during the timeservice is being offered. The Back-end department on the other hand tracks andresolves billing edits, conducts timely submission of the facility’s claims topayors and follows up on outstanding accounts.
In addition, the departmentposts denials and engages in accurate payment recording. The clinicaldepartment is only involved in obtaining patient consents and waivers. Themanagement on the other hand ensures communication and timely feedback for allstakeholders involved in the reimbursement process. Management also monitorsperformance, reviews revenue cycle metrics, and analyzes trends regardingreimbursement.Abbey(2008) points out that the billing and coding department is responsible forensuring that a hospital complies with medical billing and coding policies.This department involves front office administrators and back office staff suchas the medical billers and coders. The main responsibilities of this departmentare to understand the individual patient responsibility for payment.
Thisresponsibility differs from one patient to another. The department also has theresponsibility of analyzing medical charges, insurance coverage and preparingaccurate billing forms. In addition, the department is tasked with the actualcollection of payments from individual patients or insurance companies.
Ensuringcomplete and accurate management of the coding and billing process and activelyreviewing the revenue cycle helps the organization to identify opportunitiesfor improvement and cost reduction. This in turn helps to increase theorganization’s profit margins. It results in a coordinated, scalable and robustpractice-management system. It also promotes training of staff in thedepartments to ensure proper professional fee billing. In addition, it promotesaccountability and coordination between the front-end department and theback-end department. Further, it promotes consistent, correctly documented aswell as properly communicated performance expectations and procedures.Adherence to the policies promotes effective management and reporting based on relevantperformance metrics (Harrington, 2015). ReferencesAbbey, D.
C. (2008). Compliancefor Coding, Billing & Reimbursement: A Systematic Approach to Developing aComprehensive Program.
CRC Press.Casto, A. B., & Layman, E.(2006).
Principles of healthcare reimbursement. Chicago: American HealthInformation Management Association.Harrington, M.
K. (2016). HealthCare Finance and the Mechanics of Insurance and Reimbursement. Jones &Bartlett Publishers.
Herbert, K. (2012). Hospital Reimbursement:Concepts and Principles. CRC Press.