argues that management of the reimbursement process affects profitability of an
organization. If reimbursement is not managed effectively in these departments,
billing costs will increase, collection rates will on the other hand drop resulting
in an increase in accounts receivable. This makes value of the acquisition
untenable. Proper management in the department helps the organization to attain
a site-level control as well as establish a close relationship between patients
and the physicians.
reimbursement billing depends on timely and accurate use of HCPCS/CPT codes,
which generate Ambulatory Payment Classification (APC) groups. Regular audit
checks the department to ensure an accurate and complete coding system is in
place. This ensures success in APC reimbursement for the facility. A periodic
follow-up audit on the other hand ensures the organization identifies, reviews
and rectifies inappropriate practices which impact on the facilities profits.
It highlights potential issues 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, there are three measures to gauge pay-for-performance incentives; they
are structural measures, outcome measures and process measures. Structural
measures require a facility to capture and report how the facility’s IT systems
are used in aiding clinical care. Structural measures are organizational and
professional resources related with provision of care including operating
capacity and staff credentials. These measures gauge care attributes such as
material resources, human resources and the organization’s structure.
Process 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. 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. The final measures are referred to as the outcome measures. These
measures are used to track the desired state that result from care processes.
The measures also highlight the effect of process and structure measure types
on patients. In essence, outcome measures gauge the result of the whole care
process. In this regard, structure and process measures lead up to outcome
measures. Outcome measures are also used to track satisfaction of patients with
their care (Harrington, 2015).
to Casto & Layman (2006), successful reimbursement claims go through a
processing operation comprised of skilled personnel as well monitored
processes. Although departments involved in reimbursement may vary from one
facility to the other, activities involved in the reimbursement process are
standard. The breaking down of activities 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
payors 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
(2008) points out that the billing and coding department is responsible for
ensuring that a hospital complies with medical billing and coding policies.
This department involves front office administrators and back office staff such
as the medical billers and coders. The main responsibilities of this department
are to understand the individual patient responsibility for payment. This
responsibility differs from one patient to another. The department also has the
responsibility of analyzing medical charges, insurance coverage and preparing
accurate billing forms. In addition, the department is tasked with the actual
collection of payments from individual patients or insurance companies.
complete and accurate management of the coding and billing process and actively
reviewing the revenue cycle helps the organization to identify opportunities
for improvement and cost reduction. This in turn helps to increase the
organization’s profit margins. It results in a coordinated, scalable and robust
practice-management system. It also promotes training of staff in the
departments to ensure proper professional fee billing. In addition, it promotes
accountability and coordination between the front-end department and the
back-end department. Further, it promotes consistent, correctly documented as
well as properly communicated performance expectations and procedures.
Adherence to the policies promotes effective management and reporting based on relevant
performance metrics (Harrington, 2015).
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 &
Herbert, K. (2012). Hospital Reimbursement:
Concepts and Principles. CRC Press.