Describe the impact of the departments at this healthcare organization that utilize reimbursement data.
Harrington (2015) argues that management of the reimbursement process affects profitability of an organization. If reimbursement is not managed effectively in these departments, billing costs will increase, collection rates will on the other hand drop resulting in an increase in accounts receivable. This makes value of the acquisition untenable. Proper management in the department helps the organization to attain a site-level control as well as establish a close relationship between patients and the physicians.
What type of audit would be necessary to determine whether the reimbursement impact is reached fully by these departments?
The reimbursement billing depends on timely and accurate use of HCPCS/CPT codes, which generate Ambulatory Payment Classification (APC) groups. Regular audit checks the department to ensure an accurate and complete coding system is in place. This ensures success in APC reimbursement for the facility. A periodic follow-up audit on the other hand ensures the organization identifies, reviews and rectifies inappropriate practices which impact on the facilities profits. It highlights potential issues with compliance. Follow-up audits also ensure procedures are in place to tackle issues on quality and accuracy of coding and billing processes (Abbey, 2008).
How could the impact of these departments on pay-for-performance incentives be measured?
According to Herbert (2012), there are three measures to gauge pay-for-performance incentives; they are structural measures, outcome measures and process measures. Structural measures require a facility to capture and report how the facility’s IT systems are used in aiding clinical care. Structural measures are organizational and professional resources related with provision of care including operating capacity and staff credentials. These measures gauge care attributes such as material resources, human resources and the organization’s structure.
Process measures evaluate the methods by which care is provided. This measurement reflects procedural tests, surgeries as well as other actions in the course of treatment. The measures focus on the ability of the facility to detect, diagnose as well as manage the disease. In addition, they capture the timeliness as well as accuracy of various diagnoses, appropriateness of therapy and complications that took place during treatment if any. These measures are routinely reported to the CMS, private payers as well as third-party groups to help them prepare report cards. Patients use these reports to compare quality of facilities, physicians and health plans. The final measures are referred to as the outcome measures. These measures are used to track the desired state that result from care processes. The measures also highlight the effect of process and structure measure types on patients. In essence, outcome measures gauge the result of the whole care process. In this regard, structure and process measures lead up to outcome measures. Outcome measures are also used to track satisfaction of patients with their care (Harrington, 2015).
Assess the activities within each department at this healthcare organization for how they may impact reimbursement.
According to Casto & Layman (2006), successful reimbursement claims go through a processing operation comprised of skilled personnel as well monitored processes. Although departments involved in reimbursement may vary from one facility to the other, activities involved in the reimbursement process are standard. The breaking down of activities across departments is as follows: The front-end department captures insurance data and verifies eligibility of the patient. Staff in this department also obtains referrals, conduct initial authorization as well as collect co-pays and deductibles during the time service is being offered. The Back-end department on the other hand tracks and resolves billing edits, conducts timely submission of the facility’s claims to payors and follows up on outstanding accounts. In addition, the department posts denials and engages in accurate payment recording. The clinical department is only involved in obtaining patient consents and waivers. The management on the other hand ensures communication and timely feedback for all stakeholders involved in the reimbursement process. Management also monitors performance, reviews revenue cycle metrics, and analyzes trends regarding reimbursement.
Identify the responsible department for ensuring compliance with billing and coding policies.
Abbey (2008) points out that the billing and coding department is responsible for ensuring that a hospital complies with medical billing and coding policies. This department involves front office administrators and back office staff such as the medical billers and coders. The main responsibilities of this department are to understand the individual patient responsibility for payment. This responsibility differs from one patient to another. The department also has the responsibility of analyzing medical charges, insurance coverage and preparing accurate billing forms. In addition, the department is tasked with the actual collection of payments from individual patients or insurance companies.
How does this affect the department’s impact on reimbursement at this healthcare organization?
Ensuring complete and accurate management of the coding and billing process and actively reviewing the revenue cycle helps the organization to identify opportunities for improvement and cost reduction. This in turn helps to increase the organization’s profit margins.
It results in a coordinated, scalable and robust practice-management system. It also promotes training of staff in the departments to ensure proper professional fee billing. In addition, it promotes accountability and coordination between the front-end department and the back-end department. Further, it promotes consistent, correctly documented as well as properly communicated performance expectations and procedures. Adherence to the policies promotes effective management and reporting based on relevant performance metrics (Harrington, 2015).
References
Abbey, D. C. (2008). Compliance for Coding, Billing & Reimbursement: A Systematic Approach to Developing a Comprehensive Program. CRC Press.
Casto, A. B., & Layman, E. (2006). Principles of healthcare reimbursement. Chicago: American Health Information Management Association.
Harrington, M. K. (2015). Health Care Finance and the Mechanics of Insurance and Reimbursement. Jones & Bartlett Publishers.
Herbert, K. (2012). Hospital Reimbursement: Concepts and Principles. CRC Press.
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