Question

HCM 345 Healthcare Reimbursement

Compare and contrast the various billing and coding regulatibons. Reflect on how these regulations affect reimbursement in healthcare organization. Assess the impact of regulations on reimbursement in a healthcare organization and explain what you think is working and what could be a challenge.

Answer 1

Medical billing and coding translate a patient encounter into the languages used for claims submission and reimbursement.

Billing and coding are separate processes, but both are crucial to receiving payment for healthcare services.Medical coding involves extracting billable information from the medical record and clinical documentation, while medical billing uses those codes to create insurance claims and bills for patients. Creating claims is where medical billing and coding intersect to form the backbone of the healthcare revenue cycle.

The process starts with patient registration and ends when the provider receives full payment for all services delivered to patients. The medical billing and coding cycle can take anywhere from a few days to several months, depending on the complexity of services rendered, management of any claim denials, and how organizations collect a patient’s financial responsibility. Ensuring provider organizations understand the fundamentals of medical billing and coding can help providers and other staff operate a smooth revenue cycle and recoup all of the reimbursement allowable for the delivery of quality care.

COMMON MEDICAL BILLING AND CODING CHALLENGES:-

Manual medical billing is a top challenge for provider organizations of all sizes. HIPAA may require electronic claim transmission, but the act does not mandate automation for all claim management processes. Claim submission, eligibility and benefit verification, claim status inquiry, and remittance advice experienced modest increases in automation, while claim payment and prior authorization processes actually became more manual compared to 2016.

To earn the savings, provider organizations should first commit to electronic claims management adoption, then invest in electronic data interchange (EDI) systems. EDI systems, offered through a clearinghouse or a practice management vendor, automate a range of claim management processes.

Neglecting to inform consumers about patient financial responsibility also results in inefficient medical billing. As high-deductible health plans push patient financial responsibility upwards, billing departments should align their practices with the new healthcare payment reality. Patients are becoming increasingly like payers, and provider organizations are relying on their patients for revenue.

Healthcare reimbursement is far more convoluted. The biggest difference between healthcare and other industries is that providers are paid after services are rendered. Healthcare reimbursement is often a month’s long process that requires multiple steps, each of which can go wrong at any moment, further delaying payment to the provider and potentially saddling patients with bills they don’t understand and therefore don’t pay. Ultimately, healthcare reimbursement in full isn’t even a guarantee.