Reimbursement and Revenue Cycle Essay

The revenue cycle is defined as all clinical functions and administrative activities that facilitate the management, capture, and collection of patient service revenue. The revenue cycle involves a series of processes that are usually affected using revenue cycle management (RCM) software (Penner, 2017). Some of the essential facets of the revenue cycle are outsourcing work to the third party, managing denials, dealing with posted payments, submitting claims, and determining the client’s benefits and eligibility.Reimbursement and Revenue Cycle Essay

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Reimbursement in Healthcare Organizations

Reimbursement in healthcare organizations describes the payments made by a hospital, healthcare service provider, diagnostic facility, medical laboratory, or other providers for providing a particular medical service or product. In a reimbursement setting, the government payer or health insurer covers the cost of part or all healthcare service expenses (Penner, 2017). The medical insurers assess the quality of health service delivered to the client based on its ability to contain cost and the patient’s outcomes. Healthcare service providers using the reimbursement scheme can earn higher incomes when they provide low-cost and high-quality care compared with benchmark data and peers.

What happens if services are provided to patients, but no payments are received for those services?

In cases where services are provided to the client, and no payment is made to the healthcare facility or provider, claims can be made with sufficient service delivery evidence. Healthcare organizations cannot function effectively without adequate human, physical, and financial resources. The timelines for reimbursement are also critical to healthcare service providers as it enables them to plan effectively. In other cases where services have been provided, but no payment is made, firms can have the money conversation and offer a payment plan to the clients.Reimbursement and Revenue Cycle Essay

Departmental Impact on Reimbursement

Reimbursement affects various healthcare departments differently depending on the service providers, medical insurers, and institutions involved. Pay for performance is widely perceived as a better compensation method than other conventional schemes for primary care physicians. The purpose of payment ensures that physicians are paid based on their productivity rather than the amount of time spent at work. The process may produce some sense of financial insecurity among physicians. The advantages, however, outweigh the shortcomings (Saleh and Shaffer, 2016). Some of the factors that make the method a better compensation method are that it provides for limitless compensation capacity. The compensation method motivates physicians to work harder to increase their returns, making it a better model than other compensation schemes.

Bundled payment methods are reported to limit the physicians’ freedom in the delivery of healthcare services. The limited space is because the reimbursement is not calculated based on the physicians’ performance or the time spent at work, but rather, through health risk appraisals (Penner, 2017). The reimbursement method eliminates unnecessary tests and interventions as healthcare service providers are limited as they have to minimize costs to maximize gains. The elimination of the services limits the primary care physicians to provide holistic and comprehensive care to their patients.

Responsible departments for ensuring compliance with billing and coding policies

The human resource department and the medical record departments are responsible for ensuring compliance with billing and coding policies. The departments managing the process and the revenue cycle impact healthcare organizations significantly as the process’s efficiency is determined by interdisciplinary collaboration. Most healthcare settings are shifting to value-based care, leading to redesigning reimbursement models, including in acute care settings such as dialysis centers, to emphasize accountability of healthcare costs and quality of care.

The fading away of fee-for-service reimbursement models has led to the development of effective alternatives such as bundled payment to define the revenue management cycle’s future. Bundled payment can be useful in dialysis centers as it is designed to pay multiple providers who coordinate various services (Saleh and Shaffer, 2016). The healthcare organizations comprise a multidisciplinary team comprising of different healthcare professionals engaging in collaborative practice to enhance clinical outcomes for patients. Bundled payment models are useful in implementing value-based care without exposing healthcare providers to financial risk contracts.

Impact of the departments in a healthcare organization that utilize reimbursement data

Reimbursement impacts various healthcare organizations significant in utilizing the systems as it promotes flexibility in payment methods leading to enhanced job satisfaction and improved interdisciplinary practice. The pay-for-performance form of compensation is flexible as the physicians’ appraisal is on results rather than subjective indicators. The compensation method benefits not only the physicians but also the healthcare organizations (Reamer, 2015). The physicians are motivated to work harder to maximize their returns, thereby increasing the healthcare institution’s overall productivity. The pay-for-performance compensation method is associated with better staff retention and a low turnover rate of physicians.Reimbursement and Revenue Cycle Essay

Types of Audits Necessary in evaluating Impacts of Reimbursement

Both prospective and retrospective methods audit reimbursement in healthcare organizations. While retrospective audits are performed after claims have been paid, prospective audits are completed before submitting the claims. The processes can be effectively accomplished by incorporating the efforts of internal and external auditors in regular audits.

References

Saleh, K. and Shaffer, W. (2016). Understanding Value-based Reimbursement Models and Trends in Orthopaedic Health Policy. Journal of the American Academy of Orthopaedic Surgeons, 24(11), pp.e136-e147.

Penner, S. J. (2017). Economics and financial management for nurses and nurse leaders. New York: Springer Publishing Company, LLC

Reamer, F. G. (2015). Risk Management in Social Work: Preventing Professional Malpractice, Liability, and Disciplinary Action. New York, NY: Columbia University Press Reimbursement and Revenue Cycle Essay