Understanding the Concept of Billing, Marketing, and Reimbursement
Overview: Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization. Reimbursement drives the financial operations of healthcare organizations; each department affects the reimbursement process regarding timelines and the amount of money put into and taken out of the system. However, if departments do not follow the guidelines put into place or do not capture the necessary information, it can be detrimental to the reimbursement system.
An important role for patient financial services (PFS) personnel is to monitor the reimbursement process, analyze the reimbursement process, and suggest changes to help maximize the reimbursement. One way to make this process more efficient is by ensuring that the various departments and personnel are exposed to the necessary knowledge.
Milestone Two provides you an opportunity to engage with real-world data and tools that you would encounter in an actual professional environment. Specifically, you will begin thinking about reimbursement in terms of billing and marketing. Reimbursement is a complex process with several stakeholders; this milestone allows you to begin thinking about the key players, including third-party billing, data collection, staff management, and ensuring compliance. Marketing and communication also plays a vital role in reimbursement; this milestone offers a chance to begin analyzing effective strategies and their impact.
Prompt: Submit your draft of Sections III and IV of the final project. Specifically, the following critical elements must be addressed:
III. Billing and Reimbursement
- Analyze the collection of data by patient access personnel and its importance to the billing and collection process. Be sure to address the importance of exceptional customer service.
- Analyze how third-party policies would be used when developing billing guidelines for patient financial services (PFS) personnel and administration when determining the payer mix for maximum reimbursement.
- Organize the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain your rationale on the order.
- Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
- Develop a plan for periodic review of procedures to ensure compliance. Include explicit steps for this plan and the feasibility of enacting this plan within this organization.
IV. Marketing and Reimbursement
- Analyze the strategies used to negotiate new managed care contracts. Support your analysis with research.
- Communicate the important role that each individual within this healthcare organization plays with regard to managed care contracts. Be sure to include the different individuals within the healthcare organization.
- Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete evidence or research.
- Discuss the resources needed to ensure billing and coding compliance with regulations and ethical standards. What would happen if these resources were not obtained? Describe the consequences of noncompliance with regulations and ethical standards.
Rubric
Guidelines for Submission: Your draft must be submitted as a three- to five-page Microsoft Word document with double spacing, 12-point Times New Roman font, one-inch margins, and at least three sources, which should be cited in APA format.
Billing, Marketing, and Reimbursement
Student’s Name
Institutional Affiliation
Billing, Marketing, and Reimbursement
Billing and Reimbursement
Billing
Various procedures are needed to compose a medical bill smoothly. It is crucial to review all data before sending it to other functional units and ultimately to the reimbursement department. Collecting data for billing and coding prompts critical attention across different departments to gather information for payments. Patients access personnel within a healthcare organization collect patient details, including their name, date of birth, age, cellphone numbers, physical address, primary complaint, as well as insurance information (Medical Billing and Coding Online, 2018). This registration process is essential in creating the patient’s medical file in the electronic health record (HER) for use in the billing and payment procedure.
Accordingly, exceptional customer service is important during the initial stages when the patient enters the medical facility. Furthermore, quality customer service at the reception is critical to cultivate the facility’s reputation and thus prompt the clients to recommend the organization to other people and improve the patient satisfaction rate and the facility’s revenues. Therefore, healthcare professionals should implement the three-Ps of exemplary customer service – people first, patience, and professionalism inclinations (Kodak, 2020). In this way, patients will have a positive outcome and experience and thus culminate into a thriving healthcare organization with high client satisfaction scores and a good reputation.
Third-Party Policies
Various areas should be addressed for medical organizations to maximize their payments and develop billing requirements for patient financial services (PFS). For example, third-party guidelines incorporate standards and rules that offer privacy, confidentiality, and security when filing a payment claim. That said, third-party policies assist PFS by determining the patient’s coverage type before they are registered. Accordingly, PFS utilizes the insurance data to determine the services covered under the client’s insurance policy, including the health conditions that the insurance company requires to validate reimbursement and determine the non-covered care elements within the same insurance program (Medical Billing and Coding Online, 2018). In this way, the organization can receive a maximum payment within the shortest timescale to mitigate the probabilities for declined claims.
Key Areas of Review
The fundamental review areas for the timeliness and to attain maximum reimbursement from third-party payers entails offering the correct information to mitigate payment denials, eligibility tools use appropriate reflectivity in client’s responsibility, verify client’s tendency to reimburse, and gather money from patients before offering care. Gathering accurate and up-to-date patient information is paramount to mitigate claims declination and maximize reimbursements. Incorrect information contributes to costly days within the reimbursement cycle. Secondly, it is essential to sustain eligibility instruments to ascertain whether the client has active insurance coverage and identify any copayments and the potential deductible. Third, it involves expanding reflectivity into the client’s duty by designing programs that enable them to view their funds. These assist patients in understanding their financial responsibilities. Fourth, verifying the client’s capacity to pay offers information concerning reimbursement estimates that the healthcare facility should expect. Lastly, it is essential to collect funds before offering care since this system provides reimbursement plans. It is indicated to enhance the accounts receivable effectiveness and collection rate (Riley, 2015).
Structure
It is essential to incorporate a comprehensive and consistent audit team tasked with ensuring follow-up efficacy. This includes health sustenance care after treatment administration to ascertain the patient is improving. Accordingly, follow-up messages are essential to the recuperation process and should adhere to the set guidelines. They should be recorded for effective patient health documentation, coupled with the need for appraisal by the organization’s steering committees. Critical monitoring and assessment of follow-up messages or calls foster health services’ quality improvement efforts and control ends. Patient details to be considered includes medical status, call attempts, appointment status, health issues, patient’s post-discharge actions, as well as necessary follow-up activities implemented by staff (U.S. Department of Health and Human Services, 2013). The inclusion of the audit and assessment team guarantees effec...