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3-2 Final Project Milestone One
HCM 345
SNHU
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Reimbursement
Healthcare reimbursement refers to the process in which payment is made to
healthcare service provides for the services that have been provided to the patients. The
payment could be made by insurance companies or by the patients themselves. The
timely nature of the reimbursement process can play a cardinal role to influence how
effectively a healthcare facility can function. According to the World Health
Organization (WHO), reimbursement acts as a pivotal financial mechanism that enables
as well as encourages quality of care that is delivered to the patients. The manner in
which funding flows from insurance agents or payers to the front line to reimburse care
services influences how effectively care service providers can function (World Health
Organization, 2018, p. 9). A healthcare facility must carefully ascertain who should act
as the ultimate gatekeeper of the billing process so that the reimbursement function and
be carried out in an efficient and seamless manner. Having a well-designed
reimbursement model in place can help to avoid situations where care services are
provided to the patients but no payments are received for such kinds of services. In case
services are provided to patients without receiving any payment for the same, then
healthcare facilities would fail to function and deliver healthcare services to the general
public. Healthcare facilities have a high reliance on reimbursement to deliver quality
care services to patients in a timely and efficient manner. The lack of reimbursements
would cripple them in the long run.
Flow of the patient through the Revenue Cycle
The revenue cycle acts as a chief element of the reimbursement function in the
healthcare setting. A series of steps and processes are involved in the cycle that must be
conducted so that revenue can be generated by a healthcare facility. The revenue cycle
starts when a patient is registered into the system. The receptionist collects and verifies
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information about the patient such as the name, address, insurance information, etc.
Then the physician uses the recorded information to put the services that have been
provided to the patient. It is followed by a utilization review process where providers
get the opportunity to optimally manage their resources. Specially trained staff identifies
the medical procedure and document the same in the medical record of the patients. A
follow-up with the third–party payers such as insurance companies is done for collecting
payment on behalf of the patients. Healthcare service providers submit claims for the
services that have been delivered to the patients. Claims editing is an integral process
that helps to identify errors before they are submitted to the payers. If partial amount is
paid by insurance companies then it is the responsibility of the patients to pay the
remaining money to the service provider (Manley & Satiani, 2009). The back-end of the
revenue function involves bill processing, cash postings and collections. The remittance
processing enables patients to get a clear picture of the payment that they are expected
to make for the care services that have been provided to them. The process comes to an
end when the entire reimbursement money is received and has been posted in the books.
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II Departmental Impact on Reimbursement
Impact of healthcare organization departments that utilize reimbursement data
In the healthcare reimbursement and revenue process, many departments are
involved and thus the process impacts each one of them in diverse ways. For instance,
departments need to obtain relevant insurance information about the patient. The process
comes to an end only when the ultimate payment has been received for eh services that
were delivered to the patient. The attempts that are made to receive the entire
reimbursement amount are what ensures that the revenue cycle continues to move
forward. In case, any process or activity is not carried out smoothly by any department
then the effectiveness of the revenue cycle could get compromised.
The first departments in a healthcare organization that utilize the reimbursement
data are involved in registration, verification of the insurance details and preregistration
activity, financial counselling as well as contract management. The process that is
carried out in the front-end is of paramount importance for the patients. This is because
these activities help the patients to become aware of their coverage, eligibility and other
details. The department responsible to manage the charge capture ensures that all the
details relating to the patient details and the rendered care services are recorded in an
accurate and consistent manner. The Clinical Documentation Improvement (CDI)
program can be conducted to make sure that the health records are accurately captured
and the entire process is aligned with the reimbursement process. Conducting an audit is
crucial as it can help to ascertain whether the reimbursement impact has fully reached
by the relevant departments or not. According to Catalyst (2020), in the healthcare
setting, the pay for performance is of cardinal importance as it interconnects
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reimbursement to the metric-driven results (Catalyst, 2020). The impact of the
departments on the pay for performance incentives could be measured by focusing on
performance in terms of process, quality as well as efficiency. The domains that must be
considered for measurement include clinical care, safety, cost reduction and efficiency
and patient and care provider-centered experience.
Departmental activities
It is the responsibility of the healthcare facility to make sure that the patients are
educated and made aware of their payment obligations. This process can be carried out
by involving financial counsellors. When the front-end activities are carried out, the
healthcare staff is responsible to collect the demographic details relating to the patient.
Capturing all the details relating to the patient is vital as it can ensure that the revenue
management process is carried out in a smooth manner without any kinds of delays. The
charge capture activity is very important to make sure that a successful and effective
revenue management model is in place. This activity could be carried out by separate
departments. But since the activity has the potential to impact the entire healthcare
facility, it could also be carried out in a centralized manner.
Responsible department for ensuring compliance with billing and coding policies
The department that is responsible to ensure compliance with the billing and
coding policies is the Health Information Management department. It would be
responsible to take care of all the aspects relating to the recording of details of the
patient, codes that are adopted in the facility and the adherence of the codes with the
latest coding and billing standards in the healthcare industry. The Health Information
Management (HIM) department would be playing a cardinal role in a healthcare facility
to influence the reimbursement process that is adopted. The HIM department would be
responsible to track the details relating to the patient from the very registration stage
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(What Do Health Information Managers Do?: University of Wisconsin HIMT. UW
Health Information Management & Technology, 2020). The involvement of the Health
Information Management department would be critical even through the billing stage. In
fact, the key to the effective management of revenue cycle and reimbursement in the
healthcare facility would rely on the ability of the department to manage the health
information of each of the patients including the care services that have been delivered
to them by the healthcare facility. It would be also responsible to manage the billing,
coding and documentation processes by focusing on the compliance aspects (What Do
Health Information Managers Do?: University of Wisconsin HIMT. UW Health
Information Management & Technology, 2020).
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References
Catalyst, N. E. J. M. (2020). What Is Pay for Performance in Healthcare? NEJM
Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0245.
Manley, R., & Satiani, B. (2009). Revenue cycle management. Journal of vascular
surgery, 50(5), 1232-1238.
World Health Organization. (2018). Delivering Quality Health Services: A Global
Imperative. OECD Publishing.
What Do Health Information Managers Do?: University of Wisconsin HIMT. UW Health
Information Management & Technology. (2020, January 21).
https://himt.wisconsin.edu/about-himt/what-him-managers-do/.
