Introduction
Healthcare institutions’ mandate is that of providing health services to patients. For this to be successful, it requires funds that normally come in reimbursement. Reimbursement mostly comes from third parties, insurance, and government medical cover such as Medicare. For reimbursement to be facilitated, billing needs to be done, tallying the expenditures of patients in the health center. The policies of third parties play a critical part in the creation of billing policies for patients in the payer mix for maximum disbursement. It is paramount for health institutions to negotiate with third parties to access equitable and fair contracts. This will facilitate payment of services in a fair, prompt, and reasonable manner, and the health facility will receive its due remittance for efficient hospital management.
Discussion
The billing department must formulate guidelines for a health institution to collect its maximum reimbursement in time. These guidelines will be utilized by the front desk to get the necessary details from the patients to facilitate the preparation of bills. Such guidelines include the collection of accurate data on the patient to minimize billing errors (Bajowala, 2020). Failure to collect the right information will lead to failure to claim reimbursement from third parties such as insurance. This might lead to revenue losses to the institution that may lead to unnecessary financial losses. Another guideline is to validate if the reimbursement is paid accurately. When payments are made, it is paramount for the billing department to confirm if the payment is accurate. If errors arise, steps need to be taken to collect the right reimbursement from the insurer. In some instances, the reimbursement does not take place even though the details are filled in correctly. This normally occurs when the patient is not covered by a third party. Thus, it is important to verify if the insurance coverage is active.
Due to the importance of the revenue cycle in the running of any institution, it is important to have a structured follow-up staff to follow up reimbursement. The structured approach requires the backend staff to resolve and track billing edits, make timely submissions to third parties, and make follow-ups on outstanding A/R (accounts receivable) balances. The accounting department needs to look at the A/R and its metrics around collection rates and manage denials. The technical team focuses on billing and claiming reimbursement from insurance institutions. They are tasked with interacting with the patients and the hospital. This structure needs to be tested over and over to be effective and efficient.
For this to be effectively undertaken, plans for timely review to look into compliance with the policies need to be formulated. These include creating written procedures and policies in the compliance plan, which outlines how the institution will steer to meet maximum reimbursement. It needs to identify ways to mitigate the loss of revenue. Secondly, for the plan to be effective, it needs a compliance officer who can enforce the compliance plan. For the plan to be effective, it requires monitoring for it to be fully enforced. Thirdly, it creates effective communication lines between the compliance officer, billing team, and front desk. This will increase the collection of reimbursement. Lastly, it is to look into the plan’s feasibility to improve reimbursement in the hospital. This will determine if the plan is workable to improve the revenue collection in the institution.
Marketing and Reimbursement
Managed care contracts are a model focused on providing high-quality healthcare while reducing the cost arising from treatment. This is done by integrating quality and healthcare outcomes while simultaneously delivering standardized care in managed care. In managed care, the caregivers take part in the risk of providing care to the patients. For instance, if the cost of healthcare outweighs the capitation payment, the provider shoulders the remainder of the cost (Stadhouders, 2019). An example of a managed care reimbursement is the Medicare comprehensive plan. This module provides capitation payments to a managed care institution towards covered members per month when they provide care.
Corporate compliance covers a comprehensive range of ethical and legal aspects, facilitating confidentiality and privacy of patient data, thus maintaining the physical environment. For this to be done, internal auditing of the firm’s finances needs to be done and, in some instances, sourcing external auditors, thus complying with regulations. Errors emanating from coding and billing have severe consequences, including an allegation of fraud, criminal penalties, and substantial legal costs.
The key stakeholders in reimbursing reimbursement are the payers, the healthcare providers, and the patients. For it to be ethical, it requires that each stakeholder’s voice is heard and considered. Thus, the voices of the patients, their caregivers, and their families need to be heard for long they have been sidelined. Considering the voices of all will facilitate the betterment of services being delivered. Negotiations among the stakeholders to improve quality and minimize costs. Through negotiations, a win-win outcome is possible, where the interest of each stakeholder is addressed.
Conclusion
Reimbursement is a key source of financing for health facilities to manage to provide quality care to their patients while avoiding financial stress. Thus, it is important for each department in the institution, from the front desk to the billing department, to track payment. Managed care contracts are a model that is centered on the provision of quality healthcare at a caped price. In this model health care provider shoulders the remainder of the cost.
References
Bajowala, S. S., Milosch, J., & Bansal, C. (2020). Telemedicine pays billing and coding update. Current Allergy and Asthma Reports, 20(10) Web.
Stadhouders, N., Kruse, F., Tanke, M., Koolman, X., & Jeurissen, P. (2019). Effective healthcare cost-containment policies: a systematic review. Health Policy, 123(1). Web.