Essay Example on Effective Billing and Management of Revenues

Introduction

Changing trends in the health care industry directly influence the reimbursement processes for service providers. Programs such as Medicaid and Medicare have partially altered how health care organization remit payment for service providers and the amount they pay for the services. Negotiating contracts with insurance agencies have ensured that providers receive partial payment for the initial fees charged. Further, policies and regulations aimed at eradicating fraud and abuse in the healthcare industry have caused a rigorous observation of the claims submitted. Thus, most organizations are seeking ways of refining and improving their revenue cycle processes. This paper recommends new practices of ensuring consistency and rationalizing the overall revenue cycle process.

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Step By Step Process for Revenue Cycle

Patient scheduling is the first phase of the revenue cycle. The step requires organizations to use a checklist to obtain the necessary and needed information. Information about the patients' insurances can assist personnel to understand specific information that should be gathered. Here, the organization should perform insurance verification and inform patients about any copays needed. Once patients have arrived for the appointment, they should be taken to the second stage, which is patient registration where their basic information is verified. In this phase, new patients should fill information forms while regular ones should do it annually. Moreover, any needed co-payment should be retrieved.

Documenting records is critical in payment and success (McComas, 2018). The organization should formulate and implement a policy that outlines specific areas of record documentation. After record documentation, the next step is coding, where accurate information about education and continuous training related to coding changes and needs are gathered. Using health records of patients can help identify the most appropriate and applicable codes. Charge entry is the next revenue cycle phase after coding. Fundamentally, failing to complete the charge entry process at the correct time can directly influence the reimbursement regardless of whether coding has been completed appropriately or not (McComas, 2018). Once any mistake is identified, immediate corrections should be done as this will avert similar cases from happening in the future. Potentially preventable errors could form the principal reason for the denial of a claim.

Claims transmission is an immediate step after the charge entry where claim denial is handled and new policies implemented to eradicate reoccurrences of such mistakes. Denial management is the last step in the revenue cycle in which denials or reduced payment often occurs. These consistent challenges can be solved by proper monitoring and instant recourse, as well as a reconciliation of identified issues.

Pricing Structure

The structure and size of an organization differ across the globe. Organizations with larger sizes often have numerous payers who create various bases for payment. As such, developing a pricing structure is essential for efficient organizational longevity. Rational systems for pricing need to adhere to many ideas such as cover every requirement, be simple to operate and convey, allow buyers to easily compare different prices and looking for services, ensure that there are effective company process and organizational stability (Healthcare Financial Management Association, 2007).

The intricacy of pricing structures compels organizations to evaluate several competing goals and ideas such as aligning with the company's mission adhering to all the pertinent regulations and guidelines, delivering quality care that enhances access for every member of the community and remaining competitive within the market (Healthcare Financial Management Association, 2007).

Factors to Consider When Negotiating the Contract

Terms of the offer is a crucial factor to consider in contract negotiation. The next consideration is the understanding of the significant payers that the organization will transact with. For this practice, the considerable payers include Medicare, Preferred Provider Organization, Medicaid, Health Maintenance Organization, and private health insurance, among others. Some other critical factors to consider in contract negotiation include whether techniques are understandable, whether fees cover the actual cost of organizations, the authorization process of the payer, time allocated for one to appeal the denial, the fee schedule of payers, specification for extra physicians or enactment of new services, as well as, detailed elaboration of a cancellation clause (Gesme & Wiseman, 2010).

How an Organization Will Handle Charity Care and Self-Pay

Efficient running of practice requires an organization to develop and implement policies that address different situations such as charity care and self-pay. For self-pay patients, the organization should develop a well-written plan that deals with payment practices and effectively states that payment is the sole responsibility of patients. Similarly, policies formulated for charity care should clearly outline specific methods that are considered as charity cares. The patients should be allowed to apply before determining their eligibility in charity care. Doing this requires assessing the financial needs of patients.

Recommending a Software System

The two types of software that the organization can choose include web-based solutions and installed solutions. Web-based software can be accessed from anywhere, does not require installation, backups are often provided by vendor among others. However, they increase the chances of losing data access and have high long term costs. On the other hand, installed solutions do not need internet, do not lose data access, and can be customized. However, reports indicate that they must be installed physically in every computer and requires the company to create their backup systems (Parks, 2016).

The critical limitation of installed solutions is that they cannot be accessed everywhere. However, the limitation of losing access to data through a web-based solution is the biggest threat. The problem of location can be easily solved as compared to that of being unable to access critical data of an organization. This benefit, together with reduced cost make installed solutions the most appropriate software for the increased productivity of the organization.

Benefits of the Change to Patients, Clinic, and Physicians

To the clinic, the change will bring together the business and clinical sides of the organization. In particular, the new processes can openly streamline the billing cycle, therefore, improving the overall efficiency (Parks, 2016). Similarly, physicians witness reduced potential claim denials, thereby increasing their possibilities of getting increased pay at the right time. On the other hand, the patients will be able to connect and access all their health information records in a central place. Further, they will quickly get a copy of their health data. Besides, they will be able to pay their bills digitally and receive quality care (Parks, 2016).

Conclusion

Effective billing and management of revenues ensure the longevity of organizations. As changes occur through government and other agencies, effective billing and management of revenues enable an organization to increase its reimbursement and quality of services it offers. Consequently, this produces processes that strengthen the basis of the business and promotes the loyalty of an organization.

References

Gesme, D. H., & Wiseman, M., (2010). How to negotiate with health care plans. Journal of Oncology Practice, 6(4), 220-222. doi:10.1200/jop.777011

McComas, H., (2018). Revenue cycle management in medical practice. Retrieved May 23, 2019, from https://www.stepsforward.org/modules/revenue-cycle-management

Parks, T. (2016, May 6). Revenue management tips for physicians: Improve your financial health. Retrieved May 23, 2019, from https://www.ama-assn.org/practice-management/career-development/revenue-management-tips-physicians-improve-your-financial

Healthcare Financial Management Association. (2007). Reconstructing hospital pricing systems: A call to action for hospital financial leaders. A Report from the Patient Friendly Billing Project.