Healthcare practices must contend with many challenges throughout the year, from adopting new technologies to managing health outcomes for any number of patients. Numerous factors can add up to have a dramatic effect on revenue cycle management, creating positive - and negative - changes in providers' bottom lines.
Medical practices are businesses, and funds must be controlled to maintain profitability. According to a survey from TransUnion Healthcare, three-quarters of patients believe that knowing their out-of-pocket costs for treatments would improve their ability to pay for health services.
The poll included more than 700 respondents who were insured healthcare patients. In contrast to the initial 75 percent, the results also showed that 56 percent either rarely or never received a cost estimate before treatment, and 59 percent said they were surprised by the costs they were responsible for.
Inform to collect
One of the biggest revenue cycle challenges providers face is the timely collection of payments. Often, when a large medical bill is issued to a patient, he or she is surpri...
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
The current health care landscape has been characterized by large scale consolidation and vertical integration of payers and providers. This has led to a handful of dominate players with substantial influence, and an increasing overlap in responsibilities between payers and providers. Although payers and providers have traditionally been on opposing sides, battling each other about quality of care versus cost-effective care, they are shifting to working together to achieve better value.
The chargemaster is an integral element of the revenue cycle. It is used in generating charges for services that are rendered to patients in real time, the absence of functioning chargemaster can result in potential collapse of the revenue cycle. Hence, the process to optimize revenue cycle must include optimizing the chargemaster and all services that is associated with it. The negative consequences of nonfunctioning chargemaster can include excessive payment/overcharging, inaccurate billing to patients; and can result in stiff penalties and fines (Bielby et al,
The revenue cycle is a flowchart that explains where a patient goes after registration. Registration in charge of registering the patient, and making sure the patients have signed their in-patient consent forms. After all the information is recorded into EPIC, you will then move on to scanning. In scanning, the employee is responsible for scanning in the history and physical document, the informed consent form, monitoring strips, and EKG’s. After all the documents are scanned into OnBase, you will then move onto indexing. In indexing, the employee indexes all the documents that were scanned into the patient’s chart. Once all the documents are indexed into patients charts in EPIC, the coders will code the patients’ charts. Coding will check
A recent phenomenon in the health services is the burgeoning of outpatient healthcare centers. Particularly vigorous growth has been observed in centers that perform diagnostic tests and simple surgeries and procedures like colonoscopies. At the current state, outpatient care centers outnumber hospitals in Pennsylvania. Furthermore, these centers now perform one of every four surgical and diagnostic procedures in the state (Levy 2006). However, the trend applies nationwide, and other states could easily follow suit. Many critics have commented on the negative and positive aspects of this trend. What remains to be determined are the long term effects (on health and the economy) of this paradigm shift, in terms of the wellness of the community as well as economically. Proponents of the movement have pointed to the lower overhead for these clinics trickling down to lower costs for patients. However, critics skeptically question whether the real benefits are for the patients or simply as a mechanism to stuff physicians' wallets. When considered as firms in the marketplace, it is evident that these two groups, both servicing the health needs of the community, have vastly different balance sheets and income statements. This transfers over to a difference in operational functionality, profitability, and cost structure. Furthermore, the disparity of financial motivations that is visible in the varying profit margins is of concern to the community. All of these are important considerations to be made when considering the economic implications of this new phenomenon.
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
The health of the American people lags behind those from other developed countries. Federal public health agencies have a wide range of responsibilities and functions which includes public health research, funding, and oversight of direct healthcare providers. It has been a long time since changes have been made to the way the federal government structures its health care roles and programs outside of Medicare and Medicaid (Trust, 2013). With healthcare reform on the horizon now is the time to invest time and money in prevention, not medicine, making it a top priority to improve health and prevent disease. Funding efforts at all levels of the public health continuum need to focus on developing programs aimed at such leading initiatives as tobacco cessation, improving nutrition, supplying safe workplaces, and increasing physical activity in all ages of the population. People should have equal access to quality preventative medicine and education.
There are several issues concerning the uninsured and underinsured patient population in America. There are many areas of concern the congressional efforts to increase the availability of health insurance, the public image of the insurance industry illustrated by the movie "John Q", the lack of good management tools, and creating health insurance coverage for all low income Americans. Since the number of uninsured Americans has risen to 43 million from 37 million in the flourishing 1990s and could shoot up even more severely if the economy continues to decrease and health care premiums keep increasing (Insurance No Simple Fix, 2001).
If the United States had unlimited funds, the appropriate response to such a high number of mentally ill Americans should naturally be to provide universal coverage that doesn’t discriminate between healthcare and mental healthcare. The United States doesn’t have unlimited funds to provide universal healthcare at this point, but the country does have the ability to stop coverage discrimination. A quarter of the 15.7 million Americans who received mental health care listed themselves as the main payer for the services, according to one survey that looked at those services from 2005 to 2009. 3 Separate research from the same agency found 45 percent of those not receiving mental health care listing cost as a barrier.3 President Obama and the advisors who helped construct The Affordable Care Act recognized the problem that confronts the mentally ill. Mental healthcare had to be more affordable and different measures had to be taken to help patients recover. Although The Affordable Care Act doesn’t provide mentally ill patients will universal coverage, the act has made substantial changes to the options available to them.
Patient Protection and Affordable Care Act is the real title of the bill, enacted in 2009. It is far better known as The Affordable Care Act or Obamacare. This bill represents the biggest revolution and improvement, or at least an attempt towards it, in the health care of the United States of America since the passage of Medicaid and Medicare in 1965. The main purpose of the ACA implementation was, as the bill states in its title, to make: ˝ Quality, Affordable Health Care for All Americans˝ possible. Before the ObamaCare, there were millions of American who were uninsured, or had poor quality insurance plan. On the other hand those who did have health care coverage, even the decent one, we left on their own when insurance companies abused their trust and deprived them of their rights. That was the reason why the government and the President Obama, hoped to increase the quality and make the health insurance more affordable. The idea was to lower uninsured rate by firstly increasing the extent of public and also private coverage, and then secondly, to minimise the costs of health care for both individuals and the government.
The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.
The revenue cycle must be managed . It should be mechanized with everyone in the operational chain understanding there role. There can be several steps in the management of the revenue cycle. They include he preservice management, to management of claims, denials and posting.
Financial executives in the healthcare industry rely heavily on cash budgets to help facilitate in the forecasting of cash flows and decision making on any additional financing that may be needed (Cleverley, Cleverley, & Song, 2012). Of course the budgets are not a guarantee that the forecasted plans will go accordingly as they were planned, but with close monitoring, management will be able to make any adjustments as needed for business needs. Businesses can choose to utilize a fixed budget or decide to go with a rolling budget period. A fixed budget is more traditional annual forecast for most firms and a rolling budget differs from the traditional way in regards to its timeframe and more comprehensive analysis (Hill, 2016). The traditional
There are several factors that contribute to the complexity of the revenue cycle. Frequent changes in contracts with payers, legislative mandates, and managed care are just a few examples of reasons why revenue cycle in the healthcare industry is so complex. Furthermore, the problems that arise in the steps of the revenue cycle further complicate the whole process. For example, going through the steps of the revenue cycle efficiently is extremely difficult when it is managed by poorly trained personnel. Furthermore, if a healthcare provider does not have the proper information system to track patient records and billing, receiving reimbursement can become difficult. In addition, one of the main factors that delay payments is denial from the insurance companies. The reason for Denial includes incorrect coding, the certain sequence of care and medical necessity or even delay in submitting claims. Lastly, inefficient patient correspondence can not only hinder the process of revenue cycle but also result in many patient complaints (Wolper, 2004).
reimbursement determinations. As a result, the camaraderie among physicians has developed into a more aggressive approach to impede competition (Shi & Singh, 2012). Little information is shared with patients in regards to procedures or disease control. The subjects are forced to rely on the internet for enlightenment on the scope of their illnesses (Shi & Singh, 2012). Furthermore, the U.S. health care system fails to provide adequate knowledge on billing strategies for operations and other medical practices. The cost in a free system is based on supply and demand and is known in advance of hospital admission (Shi & Singh, 2012). The need for new technology is another characteristic that is of interest when considering the health care system. Technology is often v...