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Healthcare Organizations Revenue and Reimbursement


The process of billing is crucial for the clinic in question because it allows physicians to receive payments for their services, enabling proper functioning of the establishment. However, because the healthcare provider adopted a system in which each staff member submits claims personally, controlling the reimbursements and minimizing the number of errors is difficult. This paper will review the revenue cycle for healthcare organizations that can be carried out by the billing office, and offer improvements in the form of billing software.

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Revenue Cycle

The process of care provision begins with the scheduling of an appointment during which primary information about the patient is gathered. It is necessary to ensure that the data provided is correct and the clinic can bill the insurance company for the services. Pre-verification of insurance is done by contacting the insurance company to pre-authorize a patient’s visit and identify whether an individual is eligible for particular services (Arora, Moriates, & Shah, 2015).

At this stage, the clinic can determine the charges that the patient will have to pay on his own. This process can be carried out via a phone call or online, depending on a particular insurance company. In some cases, insurance information gathering and pre-verification can be done upon check-in. It is the initial step during which it is necessary to collect primary data because the clinic will further use it to bill the insurance company.

During the check-in, the clinic’s personnel has to make copies of the patient information, verify their identity, and cause for a visit. During this step, an individual should sign an authorization for releasing the data to the payer (Arora et al., 2015).

The Health Insurance Portability and Accountability Act provides details of this requirement. If the patient has Medicare, Advance Beneficiary Notice (ABN) has to be given, if the clinic has a reason to believe that the program would not pay for the services (“Advance Beneficiary Notice,” n.d.). The next stage includes filling out a superbill with applicable information and determines the number of co-pays, in cases where they have to be collected. This step is essential because the establishment has to inform the client of all possible charges and program eligibility.

The eligibility verification process begins with preparing the documents that the clinic will use to bill a patient. A manager prepares an account for billing using the information previously collected from a patient. The next step involves coding and capturing information regarding the services that a patient received. At this stage, the superbill is composed of information that would allow the clinic to receive payment for their work.

The form should be filled with CPT and ICD-9 codes supported by documentation from a physician (Arora et al., 2015). The process is crucial because in cases where the superbill is not submitted appropriately the clinic will fail to receive reimbursement. Upon checkout, the bill should be discussed with the patient to clarify all components and possible fees.

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Claim submission is made on a daily or weekly basis, which includes the process of reviewing information to minimize the number of errors. It is necessary to avoid denials or mistakes and thus to receive the revenue in time. Then, the forms are sent to an insurance company or patient, depending on a specified contract. The clinic either accepts payments or explanation of what mistakes were made in the superbill. Accounts receivable is an essential aspect of financial management because according to Medical Economics (2015), “the older bills get, the harder and more costly they become to collect” (para. 1). It is necessary to correct errors and resend the claim to receive the payment.

Pricing Structure

The pricing strategy for the clinic should be created to leverage income and allow flexibility when negotiating insurance contracts. According to Becker’s Hospital CFO Report (2015), daily operations of a clinic have to consider to achieve excellent profit margin and quality outcomes for patients. It is because the financial strategy requires receiving payments from insurers, individuals, and state or federal organizations.

Arora et al. (2015) state that for most healthcare establishments a “chargemaster” list is a must because in it the organizations can provide information regarding prices for each service. However, these numbers are usually higher than the actual reimbursements costs. This presents a variety of bargaining options when negotiating contracts with insurers and allows the clinic to collect higher revenues from private pay (Arora et al., 2015).

The clinic should present data in regards to some patients and services and quality measurements to receive a fair deal. Primary payer categories that should be considered when negotiating insurance contracts are reliable, distracted, disrespectful, professional debtors (Cooper, 2017). Structuring the patients in such a manner will allow highlighting the existing issue in the establishment.

One issue that may be presented by the approach is the population unable to seek insurance and provide payment for healthcare. In this case, charity care can account for procedures deemed necessary by medical professionals. The process of handling charity care and private pay begins with identifying an individual or organization responsible for reimbursements. In cases of charity care that is a state or federal-funded establishment, while private pay bills are sent to the patient directly. The process is part of the financial strategy for this organization because the clinic has to check patient information and insurance before providing services. Thus, the billing office has to determine the payer before proceeding with other steps.

Billing Software System

DrChrono HER can help the billing office to handle payments and create reports for operational improvements. Software Advice (n.d.) provides a list of 287 systems that can be used to manage billings for this clinic. The main differences to consider are price, size of the practice, and deployment. Due to the fact that the clinic in question accommodates a large number of physicians, a cloud-based application that allows handling payments for over 50 professionals is required.

DrChrono HER and athenahealth EHR both fit the requirements; however, the latter has more positive reviews (Software Advisor, n.d.). The limitation with athenahealth HER is the lack of categories for specific reports. DrChrono HER is compatible with multiple devices; patients will be able to manage bookings through the system, which will minimize the time for the process. The limitation is a need to provide training to the staff members to ensure that the software’s application is compatible with the financial strategy.

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Benefits of these Changes

The advantage of the new system is displayed by the increased accuracy of claiming payments. According to Becker’s Hospital CFO Report (2015), proper payment processes mitigate the number of denials and ensure adequate revenue reimbursement. Additionally, it is easier to review the operations of a centralized billing office will and identify errors that can be fixed, when compared to separate billing managers for each physician. The practice will ensure a better contract negotiation as well (Becker’s Hospital CFO Report, 2015). The patients will have a better understanding of which staff members to contact in case of billing issues.


The process of collecting payments is complicated and requires particular attention to each step. The thoroughly controlled billing can ensure that physicians receive revenue on time, the number of errors is minimized, and patients are informed of their option in regards to the existing laws. Thus, the clinic should consider the possibility of creating a billing office that would ensure the efficiency of the revenue reimbursement.


Advance Beneficiary Notice (ABN). (n.d.). Web.

Arora, V., Moriates, C., & Shah, N. (2015). The challenge of understanding health care costs and charges. AMA Journal of Ethics, 17(11), 1046-1052. Web.

Becker’s Hospital CFO Report. (2015). 5 keys to hospital pricing. Web.

Cooper, K. (2017). The four types of payers. Web.

Medical Economics. (2015). Accounts receivable: Strategies for better management. Web.

Software Advice. (n.d.). Web based medical billing software. Web.

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"Healthcare Organizations Revenue and Reimbursement." StudyCorgi, 17 Dec. 2020,

1. StudyCorgi. "Healthcare Organizations Revenue and Reimbursement." December 17, 2020.


StudyCorgi. "Healthcare Organizations Revenue and Reimbursement." December 17, 2020.


StudyCorgi. 2020. "Healthcare Organizations Revenue and Reimbursement." December 17, 2020.


StudyCorgi. (2020) 'Healthcare Organizations Revenue and Reimbursement'. 17 December.

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