Revenue and Reimbursement Proposal Capella Assessment
Revenue and Reimbursement Proposal Capella Assessment
A standard billing process is essential for use in various areas of care when processing claims as it improves efficiency and proficiency. In addition, a well-designed billing process also improved consistency (Nathan, 2017). The purpose of this proposal is to enhance the billing process and foster consistency. As such, a whole revenue cycle step-by-step process will be explored while at the same time recommending pricing methods and factors that impact pricing. In addition, the proposal will also cover a discussion on factors to take into account during insurance contracts negotiation. Handling of charity pay and private pay and billing software system recommendation will all be explored.
Step-by-Step for the Revenue Cycle
A revenue cycle entails a formulation of the patient account and following interconnecting steps up to payment. Therefore, a revenue cycle commences with a patient making an appointment to visit a healthcare provider. The administrative staff collects necessary patient data such as name, demographics, and date of birth to infeed into the system (Nathan, 2017). On the day of the visit, the patient is required to complete a registration form and other necessary paperwork such as payment agreements, health screening forms, and HIPAA forms. To complete the patient’s registration and check-in process, the patient’s insurance information is entered into the electronic medical record.
The patient then processes to see a registered nurse or licensed practical nurse for vitals and initial screening before proceeding to the medical provider who determines the appropriate ICD-10 codes during the patient screening. The codes are also in-fed into the EMR, which is then followed by a fee sheet to be used by the coding and billing department. This is the sheet used to trigger the billing procedure to the health insurance company (Nathan, 2017). The clerks working in the billing and coding department feed the codes into the billing system to commence the claim and reimbursement process. It is important to use the electronic-based billing system to improve on-time taken for the whole process of claim and reimbursement.
Upon claim submission, the documents are forwarded to a government payer or insurance company for reimbursements with the rates pegged on the payer contacts and the patient’s coverage. In case a claim is denied due to various errors such as improper coding, the documents can be corrected and resubmitted (Nathan, 2017). If the claim is denied because the patient is using services not covered, the billing and coding department notifies the patient to make payment arrangements. On the other hand, an approved claim is effected on the patient’s account.
The Proposed Pricing Structure
Various factors impact the pricing structure. Some of the factors include limited cost measuring ability, consumer knowledge,
and the health care exchange process structure. For this organization, the recommended pricing structure is the Fee-For-Service model. One of the things that informed the choice of the model is that it allows reimbursement for the offered services (Feeley & Mohta, 2018). The implication is that there is no or litter financial risk facing the provider. It also allows the organization to have early details on the reimbursement to be made on the services offered. Such knowledge allows easier planning since the organization will know the amount of money to expect.
Negotiation for Insurance Contact Factors
In negotiating insurance contracts, there are various things to consider. Such factors include understanding the contract language, the payer goals, and the fee or payment schedule. While the fee or payment schedule is essential for structuring how payment will be made for every service, gaining an understanding of the payer goals are key in controlling cost (Nathan, 2017). The contract language should be understood since it can negatively impact the prices. As such, the language should be easy to understand and clear to everyone.
The Private Pay and Charity Care Process
Even though many people have health insurance, there are individuals who can not afford it; hence they do not have insurance. Therefore, individuals who visit the clinic and use private pay will be made aware when making appointments that there is a minimum amount needed during check-in for a visit. After offering the services, the patient will then be given the full bills and directed to pay a discounted amount or the remaining balance billed (Goodman et al., 2020). Arrangements are then made to pay the balance as monthly installments. In case the patient breaks the agreement, arrangements will be made to collect the balance.
For charity care patients, the department will determine if the patient has and insurance cover or not. The coverage is used first if present. The patient is then allowed to apply for charity care assistance, with the value of charity care hinging on the patient’s household size and income. Upon the completion of the necessary forms, such as asset and income forms, the request is processed within two days, and approval means that the patient gets medical cover. In case of denial, other available options will be presented to the patient.
Recommendation of Billing Software
Several billing software exists today with various features. One of the most appropriate software for the organization is the NextGen Office billing system (“NextGen Office,” 2019). This system will offer the providers and medical staff access to the integrated system to improve processes such as patient scheduling and registration, among other things. This system will ensure that the procedures and the office process are streamlined to make the office operations more efficient.
The Benefits of Proposed Changes
Among the benefits include a streamlined billing and reimbursement process. When the billing process is fast enough, the reimbursement pace will also be fast, leading to increased working capital (Nathan, 2017). The system will also lead to better customer service, which will benefit everyone in the organization in terms of revenue. Again it will help create a standard of work for everyone. Standardize practice procedures benefit patients.
Conclusion
The billing and reimbursement processes are essential for an efficient operation of a healthcare organization. As such, a NextGen Office software has been proposed as the software of choice to be used for the system. The use of the system will improve various processes involving patients and providers.
References
Feeley, T. W., & Mohta, N. S. (2018). New marketplace survey: Transitioning payment models: Fee-for-service to value-based care. NEJM Catalyst, 4(6). https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0056.
Goodman, C. W., Flanigan, A., Probst, J. C., & Brett, A. S. (2020). Charity care characteristics and expenditures among US tax-exempt hospitals in 2016. American journal of public health, 110(4), 492-498. https://doi.org/10.2105/AJPH.2019.305522
Nathan, W. T. (2017). Value management in healthcare: How to establish a value management office to support value-based outcomes in healthcare. Productivity Press.
NextGen Office. (2019). A Better Way to Practice Medicine. NextGen Healthcare. https://www.nextgen.com