HIM 2133 Revenue Cycle and Billing
Module 3 Assignment
Prepare Insurance Claims for Submission
This assignment will provide you with insight into the use of data as it flows throughout the revenue cycle. Information gathered at the time of registration (demographics, insurance information, and admission date), charge capture throughout treatment and provision of services, the application of ICD-10, CPT, and HCPCs codes as well as provider information culminates in the claim form that is finalized and submitted for payment.
In this assignment, you will prepare two CMS-1500 and two UB-04 insurance claim forms using the data in four case scenarios.
To complete this assignment, do the following:
Download the zip file containing the four case scenarios below.
Download the CMS-1500 and UB-04 forms below.
Save two copies of each form on your computer (one for each of the two CMS-1500 scenarios and one for each of the two UB-04 scenarios). Save each form with a unique file name. Include the Case ID and form type in the file name (for example, CMS15001a, CMS15001b, UB2a, UB2b).
Download the instructions for completing the CMS-1500 and UB-04 forms below.
Instructions for Completing the CMS-1500 and UB-04 Forms
Using Adobe Acrobat Reader, enter the information from the case scenario into the appropriate field on the corresponding form. Refer to your readings for Physician and Hospital Medical Billing for information on CMS-1500 and UB-04 form locators and required information.
(If you do not have Adobe Acrobat Reader, download it from the Adobe website.)
For the CMS-1500 forms: Enter your name and date in the box in the upper left of the form. Enter the Case ID in the box in the upper right. Complete all pertinent fields #1-11d and 14-33 according to the data in the case and the guidelines you downloaded in Step 4.
For the UB-04 forms: Enter your name, the date, and the Case ID in the “Responsible Party” field (field 38) on the form. Complete all pertinent fields according to the data in the case and the guidelines you downloaded in Step 4.
Review and Assessment
The success of any healthcare institution is dependent on various aspects of systems working together. The revenue cycle management, which encompasses the billing system, depicts a crucial department that cannot be given a blind eye. Essentially, proper management of the financials of any healthcare organization determines whether or not it remains afloat. This essay, therefore, proposes a step by step account of the billing process, determination of the pricing structure, negotiating the insurance contracts, and handling of private pay and charity care.
The Revenue Cycle
To have the cycle functioning optimally, there should be an understanding that there is a need for system integration, which essentially combines all the electronic health records for the patient, billing, accounting, and collections. The cycle begins with sourcing for the appropriate RCM software. The software can be installed in the organization servers then managed by competent members from IT (Magray, 2016). On the other hand, it would be worthwhile to hire third-party experts to run the system if the organization expands the capacity to bring on board satellite affiliates to the institution.
Patient pre-authorization is then put in place, which in this case, efforts are made to ascertain if there are any doubts about the coverage. The necessity of the prescription, procedure, or service is determined in this step. In the next step, the eligibility and verification of the benefits are done, for instance, through secure channels with the help of a dedicated RCM software. Claims are then submitted in the next step, which is done automatically by using appropriate software.
Subsequently, payments are posted after successfully submitting the claim. The billing in this respect is done through the Electronic Data Interchange (EDI). Putting in place the appropriate denial management strategies is essential to keeping track of any claims that the insurer has turned down. The denial management helps to determine possible reasons for denial of honoring claims and therefore address them. Finally, working without reports would render operations futile. The software thus helps generate customized reports, detailing the management of information and the key performance indicators to determine whether or not the team is meeting targets.
Determining a Pricing Structure
The pricing structure settled on should be robust and straightforward at the same time. In this case, therefore, the market-oriented pricing structure should be explored. This option offers opportunities to capture a share of the market, create significant loyalty, increase demand through the utilization of economies of scale, and even stifle competitors out of the market. The strategy also confers some advantages in the long run. For instance, it can be combined with other pricing strategies to form a blend of more efficient pricing. It also offers an opportunity to increase the prices while at the same time monitoring competition. Further, this method helps to maintain operations to avoid being faced out by the competitors.
Several factors ought to be considered when determining the pricing structure for the healthcare organization. Competitors rank top as they determine whether the business could set prices independently or dependent on other healthcare organizations. The costs incurred in acquiring equipment and delivering services to the patients should also be factored in when pricing. There should also be a consideration of the state of the economy since people would be unwilling to spend when the economy is unfavorable, thus poor business.
Negotiating Insurance Contracts
Insurance plans are highly negotiable, and when doing so, there is a need to factor in some considerations. First, always consider the other party in the negotiations, determining what the payer is most concerned about, for instance, the ancillary services, then utilize them appropriately. Payers always look for cost controls and predictability, and therefore, the healthcare organization should be able to demonstrate that.
The availability of clinical data is also crucial since payers would need it as proof of compliance with clinical practice and disregard for unnecessary and expensive services. There is also a need to consider the contract language used since some payers demand prices that match public rates like Medicaid. Also, consider the appropriate authorization for the treatment course, the time frame allowed to file an appeal, and the period required to submit it. The relevant payer categories to consider would include both public and private. Important ones include Medicaid, BCBS, and Medicare.
Private Pay and Charity Care
The first undertaking when handling the private pay patients is to ensure the availability of a formal policy that is read to them to facilitate comprehension of obligation. The payment for the services by private option would be handled on a case by case basis. The private pay individuals would discuss with the presiding physician in advance regarding possible adjusted fee schedules. Later, there would be an arrangement for payment plans, like percentage charge, and the physician fee only limited the patient’s ability to pay. Before delivering the services, the patients should then sign promissory notes and make down payment in case of expensive procedures.
Regarding charity care, there ought to be guidelines and criteria definitions. Policies ought to be in place regarding the patients who suit to be considered for charity. Once determined, all medical professionals should be involved equally in rendering their services. Each of the cases should be rotated evenly to all the nurses and physicians assigned in every rotation order. The costs incurred in delivering charitable services are considered bad debts, collected, and then sent to the collection agency.
Web-based Billing Software System
QuickBooks software is appropriate billing software that offers acceptable standards in healthcare practice. It is capable of accepting business payments, carrying out the payroll functions, and managing and paying the bills (Stamper, Hartley, & Morrison, 2019). The software is also able to track the sales and profits, and it is capable of scheduling recurring payments, which saves time.
Benefits of the Changes to Physicians, Clinic, And Patients
When the RCM services provided are efficient, the physician has ample time to focus on improving healthcare services and improving the efficiency of the practice. Further, the physician’s revenue is also sustained since it is unlikely that losses would be imminent. The clinic stands to benefit significantly from streamlined operations since there would be more transparency and control over the financials. There are also reduced costs associated with the in-house operations and hence increasing the profitability of the clinic.
An efficient RCM allows for Account Receivables (A/R) reconciliation and hence follow-ups enabling the care providers to focus on delivering patient care. The clinic would also benefit in the sense that there are reduced billing errors when an appropriate software is in place; this goes a long way to build the reputation of any healthcare institution (Landman, 2016). A useful software impacts the patient because a lot of time is saved when verifying payments, and hence services are rendered fast.
When professional billing agents help in verification of all details like insurance compliance, patient enrolment, diagnosis, and treatment, there is little room for the occurrence of errors, and this increases the level of patient satisfaction. In the case of private patients, an efficient system protects them from incurring unnecessary expenses due to erroneous summations.
Landman, J. H. (2016). The value of behavioral health. Healthcare financial management : Journal of the Healthcare Financial Management Association, 70(12), 68–69.
Magray, N. (2016). SPORT FISHING, AN OPPORTUNITY FOR PROMOTION OF ADVENTURE TOURISM IN JAMMU AND \R\Nkashmir. International Journal in Management and Social Science, 4(11), 12. Retrieved from http://ijmr.net.in/currentijmss.php?p=VOLUME 4,ISSUE 11,November,2016
Stamper, J., Hartley, P. A., & Morrison, M. (2019). U.S. Patent No. 10,346,587. Washington, DC: U.S. Patent and Trademark Office.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
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One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
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Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
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Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
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