Description
1. Britt
Revenue Cycle Management (RCM) is a vital part of the acute care environment. It helps to provide organizational management to medical billing and revenue. It is crucial for the financial health of an organization to have an RCM process that is successful because it ensures timely revenue, regular collections, and financial viability. RCM also allows hospitals and health systems to focus on providing a superior patient experience. One consistent aspect of RCM no matter the facility types or service type is that revenue is managed from before the visit to safeguard payment after the visit.
With the previous fee-for-service payment method, each department worked independently of one another, and this also occurred in a retrospective manner. Now that the complexity of reimbursement has been brought to light in the prospective environment, it has become vital for all the individual departments to work together and establish a strong team in order to manage the revenue for a facility or provider utilizing an RCM strategy. With the prior method of payment, the payer did not know what they were going to be billed for until after the services were rendered.
The most effective model of the RCM is divided into three categories which in the front-end process, middle process and the back-end process. If all these categories are not properly completed, then the provider or facility is at risk of nonpayment for services rendered. In the front-end process it begins before the patient evens schedules the appointment. It is essential that healthcare providers and healthcare facilities complete the credentialing process with different payers. If this is not completed correctly then the provider or facility is at risk of being considered out of network and will then be ineligible for payment from that payer. This is also the process of obtaining accurate information regarding the patient’s demographics and insurance information to verify eligibility at the time services are performed. This category is also when prior authorization, precertification and medical necessity come in to pay. Certain payers require that different procedures or services meet criteria set by the medical team associated with that payer. If they do not see that the procedure or service meets their requirements that service will be denied coverage.
Case management, charge collection, hard and soft coding of diagnoses and procedures, all of which are based on clinical documentation, are all included in the middle step of the revenue cycle (Harrington, 2021). At this point it is essential to have all clinical documentation accurate to have accurate billing and ultimately profit.
When it comes to the back-end process, tasks such as processing invoices, posting payments, correcting claims when necessary, appealing claims, supplying patient documentation, and making any necessary adjustments to ICD-10 codes are performed.
All of these processes must be done accurately to the best of everyone involved in order for healthcare providers and facilities to be able to remain operational. Billing and coding errors can result in reversal of payments, no payments and even fraudulent activity. Therefore, having a successful RCM is vitally important. There are things called Key Performance Indicators (KPI), and they make it possible for a facility to measure or benchmark its data against the best practices. KPIs provide managers with accurate information that enables them to identify the strengths and weaknesses of the institution and improve the performance of the management team (Pourmohammadi, et al., 2018).
Poor RCM can lead to a number of disastrous outcomes, some of which are financial instability, a drop in patient volume and satisfaction, a dissatisfied working environment, bad debt, wasted time, and stagnant growth, which often results in the business having to shut down. The magnitude of the damage caused by fraudulent activity cannot be overstated because it results in the diversion of resources that were intended to help people who are in need. The overall costs of essential health care services go up because of fraud, which also has the potential to be damaging to people who get benefits from Medicare and Medicaid (Chen, et al., 2020).
There is no room for debate in the Bible that God abhors deceit. Two of the items on the list of “six things that the Lord hates, seven that are an abomination to him” in Proverbs 6 have to do with lying: “a lying tongue” and “a false witness who breathes out lies.” Proverbs 12:22 says “lying lips are abomination to the Lord: but they that deal truly are his delight” (KJV, 2020). God despises lying because he places an extremely high value on the truth and because he is the origin of every piece of truth.
References:
Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association : JAPhA, 60(6), e60–e65. https://doi.org/10.1016/j.japh.2020.05.011Links to an external site.
Harrington, M. K. (2021b). Health Care Finance and the mechanics of Insurance and Reimbursement (Second). Jones & Bartlett Learning.
Pourmohammadi, K., Hatam, N., Shojaei, P., & Bastani, P. (2018). A comprehensive map of the evidence on the performance evaluation indicators of public hospitals: a scoping study and best fit framework synthesis. Cost effectiveness and resource allocation : C/E, 16, 64. https://doi.org/10.1186/s12962-018-0166-zLinks to an external site.
The holy bible: King James Version. (2020). Hendrickson Publishers Marketing, LLC.
2. Canadra
Now that medical billing processes have changed over time, from fee for service, to prospective payment service, the revenue cycle management (RCM), that is now being performed today, ensures that the medical facilities and the providers that performed the service are paid upfront. Hospitals’ profitability and ability to grow equity are key factors in their efforts to maintain the up-to-date facilities and equipment needed to attract well-trained healthcare professionals and provide high-quality patient care (Singh, S. R., et al., 2012). This new process requires that payment is rendered before the patient is even admitted. Doing the medical procedure, which can be different across, it is important that the correct actions are annotated and documented. This means that healthcare administrators have to predict of estimate what services, supplies, and the recovery time will be needed for the patient. Again, this can vary from patient to patient, as well as from one medical location to the next. It is also important that fees covered by the patient are addressed upfront so that the patient can make the payment prior to the start of the medical procedure. It is up to the patient to cover their portion before the medical location will schedule the procedure. This cycle is also important for the organization because it is simply based off of supply and demand. Time, resources, and recovery care are all part of the medical procedure and those supplies used have to be brought again for the next patient. It’s similar to shopping. You take something of the shelf, you pay the price for it, the store can now buy it again, put it back on the shelf for the next person to purchase. Product go out and product go in, all through the cycle of purchase and sale. Without payment for services rendered, the medical facility can not provide for the next patient. If the physician is not paid for their skill, they can not work to treat the next patient. While physician billing of the encounter represents one component of revenue cycle management, recent work has demonstrated that more than 30 percent of the total processing cost for an encounter bill is for physician time. Moreover, nearly 25 percent of the total processing time of a single bill has been attributed to physicians (Chin, S., et al., 2022). The impact of not having a RCM cycle, services rendered with no payment received, would not be beneficial to the medical facility. They would not have enough funding to stay in business.
Harrington (2021), states that, “there’s three areas within the RCM which consist of the front end process, middle process, and back end process (pg. 176).” In other words, the administration process, procedure process, then the billing process. Ensuring the correct insurance information, medical procedure, and patient information is accurate must be done on the front end. Next is ensuring the coding of what was done and issued is entered into the proper system and correctly. Finally, the back end consist of the claims process and ensuring payments are posted as required. The data and information must be correct in all three processes. This is how all the systems communicate with each other and payments are made. Attention to detail and proper monitoring at all three stages are very important. If there’s an error, it can lead to missed payments, incorrect payments, no payments at all. Checks and balances to ensure everyone is on one accord requires communication to be clear and concise. This is done so that what id due back is correct and what was done was correct. Finally, this reminds of Proverbs 27:17, “Iron sharpens iron, and one man sharpens another (ESV, 2023).” This cycle sharpens the next process every step of the way. When payment is made or reimbursed, then the physician do well in there medical procedure, the hospital is paid and the patient’s quality of care is beyond the standard.
References
Chin, S.,M.B.A.M.D., Li, A., B.S.C., Boulet, M., M.D., Howse, K., M.D., & Rajaram, A.,M.M.I.M.D. (2022). Resident and Family Physician Perspectives on Billing: An Exploratory Study. Perspectives in Health Information Management, 19(4), 54-61.
https://go.openathens.net/redirector/liberty.edu?url=https://www.proquest.com/scholarly-journals/resident-family-physician-perspectives-on-billing/docview/2738608579/se-2Links to an external site.
English Standard Version Bible (2023)
https://www.openbible.info
Harrington, M.K. (2021) Health care finance and the mechanics of insurance and reimbursement. (2nd ed.) Burlington, MA: Jones & Barlett.
Singh, S. R., PhD., Wheeler, J., PhD., & Roden, Kirk,M.B.A., F.A.C.H.E. (2012). Hospital Financial Management: What Is the Link Between Revenue Cycle Management, Profitability, and Not-for-Profit Hospitals’ Ability to Grow Equity? Journal of Healthcare Management, 57(5), 325-39; discussion 339-41.
https://go.openathens.net/redirector/liberty.edu?u…
support assertions with at least 3 references and 1 instance of biblical integration in current APA format. Each reply must incorporate at least 2 scholarly citations and 1 instance of biblical integration in current APA format.
course textbook:
Harrington, M. K. (2021). Health Care Finance and the mechanics of Insurance and Reimbursement. Jones & Bartlett Learning.
