Discussion Reply- Response 1-2 paragraphs with 1-2 references

Andria Byrd

Hi Class, Happy 7th week!

For reimbursement, hospitals submit claims to Medicare. Claims are then sent to the specified Medicare Administrative Contractor (MAC) electronically (Casto, 2018). Each claim includes details about the visit, the patient, the hospital, specific charges by procedure code, and diagnosis codes (Casto, 2018). As a hospital healthcare administrator, I would focus efforts on data accuracy related to claims, such as the details about the visit, the patient, specific charges, and coding operations. Training each team member and backtesting data quality would be beneficial for ensuring clean claims. Medicare defines the term clean claim as “a claim that has no defect, impropriety, lack of any required substantiating documentation – including the substantiating documentation needed to meet the requirements for encounter data – or particular circumstance requiring special treatment that prevents timely payment”(Capline Services, 2020). Finding and analyzing patterns in vast amounts of data hospitals can improve productivity in your healthcare revenue cycle. Leakage costs hospitals between 1 and 5% of their net income (RevSpring, 2018). With ICD-10, the Affordable Care Act, and rising out-of-pocket payment volumes, this figure is predicted to rise (RevSpring, 2018). Having a system in place to capture data errors will help improve the revenue cycle overall.

Casto, A. (2018). Principles of Healthcare Reimbursement, Sixth Edition. [VitalSource Bookshelf]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781584266648/

Capline Services. (2020). What is a Clean Claim in Medical Billing - Capline Medical Billing Retrieved from https://www.caplineservices.com/blog/what-is-a-clean-claim-in-medical-billing/#:~:text=Clean%20Claim%3A%20Medicare%20defines%20the,special%20treatment%20that%20prevents%20timely

RevSpring. (2018).Use Big Data to Improve the Healthcare Revenue Cycle. Retrieved from https://revspringinc.com/resources/blog/use-big-data-to-improve-the-healthcare-revenue-cycle/

less