Reimbursement and the Revenue Cycle
In business or personal life, reimbursement refers to receiving payment to refund or compensate money already spent or an incurred expense while in a healthcare context; healthcare providers receive payment from government and insurance payers through a reimbursement system. The doctors provide medical services to patients then file for reimbursement with a government agency or an insurance company; the patients do not pay out of their pockets. In the United States, there is Health reimbursement plan which is an employee health benefit provided by some employers where employees are reimbursed for the medical expenses they incur (Torrey, 2016). The organization funds the program and in return gets a tax benefit, but the employees are not taxed on the money as income. In cases where the health plan has a high deductible, HRP can be of advantage because it allows the employees to be reimbursed for their incurred expenses before reaching deductible amount.
According to Medical Billing and Coding Online, (2016), the cases where an insurance provider does not fully reimburse for the services provided to the covered patient, the charges are transferred to the affected patient. All the relevant information of the transaction inclusive of the list of services the medical service provided is availed to the patient, and this is to make sure that the patient understands their financial responsibility. The billing procedure helps the healthcare provider avoid potential complications that they might encounter in the process of receiving reimbursement from the patient (Harrington, 2015). On the occasion where the patient does not honor the and pay the medical bill on time, the clinician will do a follow- up and handles any other extra expense, and in case the balance is not paid for a stipulated time, the health provider launches a collections process to receive the overdue bill reimbursement. The time taken before starting the collections process and the approach for the reimbursement collection is determined by the financial policy of the healthcare provider.
Data can be retrieved from a defined contribution software administration reporting feature which makes real-time monitoring of the HRP reimbursements, liabilities and utilization uncomplicated (Benefits, 2014). However, it is a dilemma to the clinicians in the cases where a patient is not covered by an insurance company and cannot solely afford to pay for the medical care. The health provider is forced to either influence the change of the reimbursement and billing rules, lower standards or dismiss the patient (Weiner, 2006). This is why it is important for the health provider first to enquire about the financial status of the patient for them to make the right decision. Where there are insurance denials and unpaid bills by both the insurer and the patients, the clinicians send the bills to the attorney or state insurance commissioner so that the parties can be held liable and pay for the expenses.
Revenue Cycle Flowchart
From the above flowchart, the first step is to collect the patient’s data and information and then establish files both in paper and electronic form. Registration is a crucial step because the hospital attendant ought to have information of the person they are dealing with at the moment. Secondly, the guarantor to the patient is established and the financial obligations of the insurance carrier revised which is a major step for the patient to understand the extent of the insurance. Thirdly, find out the insurance coverage of health care services then certify where essential. Fourthly, the doctor diagnoses the patient and provides the required medication. The services and products are HCPCS; ICD CPT coded and billed on UB-04 and CMS-1500 Universal claim forms (Kaplan, 2009). After billing and coding, they are checked for accuracy and compliance then insurance claims are prepared and emailed to the insurance company.
The other step is monitoring of the submitted claims denials and payments by the insurance carrier to determine the amount of money the patient is entitled or supposed to pay. Co-insurance, co-payments, and patient deductibles are collected together with the balance bill not covered by the insurer. The health care provider follows up with the patient and insurance carrier for outstanding balance payment then performs a maximization of the health care services (Kaplan, 2009). In the cases where the bills have not been settled, and there are insurance denials, the unpaid bills are sent to the attorney or a State insurance commissioner filing a case against the insurance company and for the patient, the unpaid bills are sent a collection service.
Benefits, Z. (2014). Healthcare Reimbursement Plan (HRP) – What is it?. Zanebenefits.com. Retrieved 14 April 2016, from http://www.zanebenefits.com/blog/healthcare-reimbursement-plan-hrp
Harrington, M. K. (2015). Health Care Finance and the Mechanics of Insurance and Reimbursement. Jones & Bartlett Publishers.
Kaplan, R. (2009). The Health Care Revenue Cycle (1st ed., pp. 1-5). New York: Doug Finney. Retrieved from http://therightway.com/downloads/Revenue-Cycle.pdf
Medical Billing and Coding Online. (2016). The process of medical billing. Medical Billing and Coding Online: Learn About the Industry!. Retrieved 14 April 2016, from http://www.medicalbillingandcodingonline.com/medical-coding-for-billers/
Torrey, T. (2016). What is Reimbursement in a Healthcare Context?. About.com Health. Retrieved 14 April 2016, from http://patients.about.com/od/glossary/g/reimbursement.htm
Weiner, S. (2006). I can’t afford that!. J Gen Intern Med, 16(6), 412-418. http://dx.doi.org/10.1046/j.1525-1497.2001.016006412.x