Introduction
Understanding the expectations of the various divisions and personnel within the organizations determines the healthcare outcomes. Each organizational division influences the reimbursement procedure regarding the schedules and amount of capital directed toward the process. One key element to track financial components is the Medical billing software, which determines copayments and verifies the insurance coverage, sending the claims digitally to the third-party payers. In a healthcare setting, a supervisor within a patient financial services (PFS) department should elaborate on how reimbursement affects other healthcare departments.
Reimbursement and the Revenue Cycle
Reimbursement Meaning to a Healthcare Organization
Reimbursement is the payment of the cash that has been allocated for utilization. In the United States, reimbursement policies constantly change since federal lawmakers amend them almost daily. Nevertheless, insurance companies are mandated to create a blueprint on how the financial system operates in the healthcare sector. The charges are made when a physician provides services to the patients, which forms the basis of a reimbursement claim. Significantly, reimbursement is essential in healthcare as it offers the much-needed capital to operate a medical facility (Harrington, 2019). Notably, if no payments are received after providing services to the clients, the healthcare would face monetary challenges, resulting in closure. At the same time, the revenue cycle entails sufferers collecting databases to facilitate reimbursement and involves three key players: payers, patients, and insurance providers.
The Flow of the Patient Via the Revenue Cycle
To a greater extent, medical facilities, including the Northeast Georgia Medical Center, constant reimbursements guarantee their operations. Notably, when a healthcare center does not acquire such refunds, it risks bankruptcy. In the United States, approximately 23 hospitals face a monetary obstacle, leading to liquidation to a lack of repayments (Harrington, 2019). Figure 1 illustrates the flow of patients from initial contact to the final destination of making payments at Northeast Georgia Medical Center. The payments made by the victims for the services offered enable the healthcare facilities to derive reimbursements.
The process commences when the medical entity officials communicate with the client in the admission division by making contact via online enrollment or calling the physician to schedule a hospital appointment. After the patients give their database, the hospital staff begins the authentication process to verify the insurance and demographics information (Wang & Wang, 2021). Afterward, an individual victim account is created to facilitate payment and treatment. The accounts division representatives prepare a charge entry in a coded system which is delivered to the client after the discharge. The medical facility accountants create a bill forwarded to an insurance firm if no conflict exists from the charges.
Departmental Impact on Reimbursement
Utilization of Reimbursement Data
Several diverse departments deploy reimbursement data in a healthcare organization. For example, Northeast Georgia Medical Center is a reputable non-profit healthcare facility that delivers cardiac care services to patients and receives approximately $2.8 billion from patient revenue (“Find a Doctor”, 2022). Notably, the medical center has large and small hospital branches that offer multiple benefits, including family care, internal medicine, pediatrics, and emergency services. The healthcare entity divisions’ management handles reimbursement data with great care to ensure the hospital’s success (Harrington, 2019). The lack of monitoring of such data makes the hospital to financial difficulties, resulting in bankruptcy. Considerably, the gathering of reimbursement data is crucial for pay-performance inducements. The internal audit assists in evaluating the hospital’s reimbursement effect on departments. The audit entails an independent appraisal process, giving insights into the firm’s financial and operational controls. The Northeast Georgia Medical Center utilizes the pay-for-performance payers’ system, ensuring the healthcare providers get rewarded grounded on exceptional victim outcomes due to quality of care, and penalizes those insurers that underperform.
Activities Within a Healthcare Organization
The Northeast Georgia Medical Center has four core departments that may influence reimbursement, including patient accounts, administration, healthcare information management, and clinical services. The victim’s accounts division is responsible for gathering the client’s data and recording it to the chargemaster to produce the reimbursement bill. On the other hand, the administration department reviews all the transactions for the healthcare facility that could transition its financial position (Wang & Wang, 2021). In addition, the department adjusts the budget accordingly when errors in the revenue cycle cause a profit decline. The clinical services department is mandated to verify the patient’s insurance and registration details and examine whether the services rendered to the client were effectively billed. Clinical services management elaborates to the sufferer the type of services offered and determines whether correcting mistakes is necessary (“Find a Doctor”, 2022). The health information department in a medical facility can impact reimbursement. Therefore, the division’s duty is to soft code of client’s medical database and ensure the accuracy of the data being reviewed.
Responsible Department for Ensuring Compliance
At Northeast Georgia Medical Center, the division that is in charge of ensuring conformity with the policies for coding and billing is the healthcare information department. Significantly, the subdivision personnel assesses whether the medical facility adheres to the existing coding guidelines, and it must be familiar with the financial obligation of the clients to the healthcare providers (Harrington, 2019). However, each department should outline the procedures for policy application to their respective locations of care settings.
Conclusion
The reimbursements help medical facilities, such as Northeast Georgia Medical Center, to avoid bankruptcy and continue providing healthcare services to patients. The flow of patients from the initial contact to the last point of making the payment is crucial in tracking the reimbursement data. The vital departments influencing the repayment include patient accounts, healthcare information, clinical services, and administration divisions. The health database department is mandated to ensure that the healthcare organization complies with the available policies.
References
Find a doctor. (2022). Northeast Georgia Medical Center. Web.
Harrington, M. K. (2019). Health care finance and the mechanics of insurance and reimbursement (2nd ed.). Jones & Bartlett Learning.
Wang, Z., & Wang, J. (2021). Reimbursement policy in a healthcare system with priorities: Fee for priority versus bundled priority.Journal of Management Mathematics, 32(3), 329-360. Web.